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in  2010  with  funding  from 

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http://www.archive.org/details/manualofoperativOObrya 


MANUAL 


OF 


OPERATIVE    SURGERY 


BY 

JOSEPH    D.    BRYANT,    M.  D. 

PROFESSOR    OF    ANATOMY    AND     CLINICAL    SURGERY,    AND     ASSOCIATE     PROFESSOR     OF    ORTHOPEDIC 
SURGERY,   BELLEVUE  HOSPITAL  MEDICAL  COLLEGE  ;    VISITING  SURGEON  TO   BELLEVUE   HOSPI- 
TAL ;    CONSULTING    SURGEON    TO    THE    BUREAU  OF    MEDICAL  AND   SURGICAL  RELIEF, 
OF      BELLEVUE      HOSPITAL  ;     CONSULTING      SURGEON      TO      THE     NEW     YORK 
LUNATIC   ASYLUM,   AND   TO   THE   NORTHWESTERN   DISPENSARY. 


WITH  ABOUT  EIGHT  UUKDItED  ILLUSTnATIOXS 


NEW  YORK 
D.    APPLETON    AND    COMPANY 

18K7 


Copyright,  1886, 
By  D.   APPLETON  AND  COMPANY, 


UMtJfclftl 


s 


>x 


TO 

STEPHEN     SMITH,     M .  D . 

AND 
TO   MY   PRECEPTOR 

GEORGE      W.     AVERY,      M.D. 
£{)is  Volume 

IS   RESPECTFULLY   INSCRIBED 

THOUGH   BUT    A    MEAGER  RECOGNITION  OF  THE   MANY   KINDNESSES 

SHOWN  BY  THEM  TO 

THE       AUTHOR 


PREFACE 


The  frequent  request  on  the  part  of  those  whom  it  has  been  my 
pleasure  to  instruct  in  operative  surgery  during  the  past  few  years, 
to  make  a  book  based  somewhat  on  the  plan  I  have  employed  in 
teaching  this  subject,  is  the  principal  incentive  to  my  action.  The 
field  of  operative  surgery  is  too  well  cultivated  already  for  one  to  do 
more  in  this  brief  space  than  aid  the  student  of  surgery  to  acquire 
established  facts.  The  works  of  Ashhurst,  Agnew,  Gross,  Erichsen, 
Holmes,  Smith,  Esmarch,  Packard,  Stimson,  and  many  others,  to- 
gether with  the  current  medical  literature,  have  been  consulted. 
The  illustrations,  which  are  numerous,  have  been  selected  in  most 
instances  from  standard  works,  although  a  considerable  number  of 
original  and  modified  illustrations  have  been  introduced.  Mr.  W. 
F.  Ford,  of  the  reputable  firm  of  Caswell,  Hazard  &  Co.,  of  this 
city,  kindly  provided  the  instrumental  cuts,  as  is  to  be  seen  by  the 
"  Index  of  Illustrations."  The  author  desires  to  acknowledge  the 
aid  derived  from  the  above-mentioned  sources,  and  trusts  the  reader 
will  find  something  to  commend  in  the  pages  that  are  to  follow. 
The  author  regrets  that  sufficient  data  are  not  at  hand  to  permit  the 
"  results  "  to  be  given  in  all  instances  as  modified  by  the  antiseptic 
method  of  treatment.  The  operations  peculiar  to  the  female  sex, 
and  the  eye  and  ear,  have  not  been  considered,  since  they  are  en- 
titled, in  the  opinion  of  the  author,  to  a  more  extended  considera- 
tion than  the  intentional  scope  of  this  work  will  admit.  The  au- 
thor desires  to  acknowledge  the  valuable  services  of  Drs.  Glover, 
C.  Arnold,  and  Herman  M.  Biggs,  in  connection  with  the  proof- 
reading, and  of  Dr.  Arnold  also  for  the  complete  indices  of  the 
book.  The  assistance  of  Dr.  A.  II.  Doty  in  preparing  many  of  the 
original  illustrations  is  likewise  gratefully  acknowledged. 

Joseph  D.  Bryant,  M.  D. 

66  W.  TuiKTY-fifTH  .Street,  New  Yor.K,  October  28,  1886. 


CONTENTS. 


CHAPTER   I. 

GENERAL   CONSIDERATIONS. 

PAGE 

Definition  of  operative  surgery — Facts  to  be  ascertained  before  operating — Season 
of  the  year  for  operating — Time  of  day — Surroundings  of  the  patient — Tem- 
perature of  the  room — Place  for  an  operation — Nursing — Preparatory  treatment 
— Diet — Essential  and  preparatory  requirements — Anaesthetics — Inflammability 
of  ether — Chloroform  more  dangerous  than  ether — Varieties  of  inhalers — 
Amount  of  ether  required — Purity  of  the  anaesthetic — Dangers  of — How  to  pre- 
pare a  patient  for  anaesthesia — Method  of  administering  ether — Treatment  for 
an  overdose  of  ether — Intestinal  etherization — Local  anaesthesia — Instruments 
necessary  for  operating — Methods  of  holding  the  scalpel — Forms  of  incisions — 
Instruments  should  be  plain — Receptacle  for  instruments — Operating  table — 
Empty  vessels — Clean  towels  and  old  linen — Antiseptic  solutions — Sponges        .       1 

CHAPTER   II. 

AGENTS   FOK   CONTROLLING   HEMORRHAGE. 

Styptics — Position — Elastic  bandage — Compresses — Digital  pressure — Davy's  lever 
— Petit's  tourniquet — Trendelenburg's  rod — Acupressure — Torsion — Forceps — 
Tenacula — Cautery — Ligatures — Assistants — Patient  prepared  .         .         -         .23 

CHAPTER   III. 

TREATMENT    OF    OPERATION   WOUNDS. 

Sutures — Needles — Needle-holders  — Various  forms  of  sutures — Drainage-tubes — 
Canalization — Antiseptic  spray — Antiseptic  douche — Antiseptic  dressings — Anti- 
septic solutions — Quietude  of  patient — Common  preparations  for  an  antiseptic 
operation — Open  dressings — Precautionary  requirements  of  operations — Special 
emergencies  of  operations 41 

CHAPTER    IV. 

LIOATUBE   ok   ARTERIES. 

Guides  to  ligaturing — Making  primary  incision — Opening  the  sheath  of  a  vessel — 
I'  -  img  ili''  ligature — Instruments  required  for  ligaturing — Ligature  of  abdomi- 
nal aorta — Of  common  iliac  arteries — Of  internal  iliac  artery— Of  gluteal  artery 
— Of  sciatic  artery — Of  internal  pudic  artery — Of  dorsalis  pedis  artery — Of  ex- 
ternal iliac  artery — Ot  epigastric  artery — Of  deep  circumflex  artery — Of  femoral 
artery — Of  innominate  artery — Of  subclavian  artery — Of  vertebral   artery — Of 


yjii  CONTENTS. 


PAGB 


internal  mammary  artery — Of  axillary  artery — Of  brachial  artery — Of  radial 
artery — Of  ulnar  artery — Of  superficial  palmar  arch — Of  common  carotid  artery 
— Of  the  common  carotids — Of  the  external  carotid  artery — Of  the  internal 
carotid  artery — Of  the  superior  thyroid  artery — Of  the  lingual  artery — Of  the 
facial  artery — Of  the  temporal  artery — Of  the  occipital  artery    .         .         .         .56 

CHAPTER   V. 

OPERATIONS   ON   VEINS,    CAPILI.AKIES,    ETC. 

Ligature  of  veins — Operations  for  varicose  veins — Injection — Acupressure — Subcu- 
taneous ligaturing — Hemorrhoids — Operation  for  internal  hemorrhoids — Ex- 
cision— Crushing — Ligaturing — Ligature  with  incision — Injection — Varicocele, 
treatment  of — By  excision  of  the  scrotum — By  compression  with  wires  or  pins 
— By  subcutaneous  ligaturing — Venesection — Transfusion — With  blood — With 
saline  solutions — With  milk — Mother's  mark — Treatment  of — Nsevi — Treatment 
of — Cirsoid  growths — Treatment  of 117 

CHAPTER   VI. 

OPERATIONS    ON   THE   NERVOUS    SYSTEM. 

Operations  for  hydrocephalus — For  meningocele — For  hydrorachis — Trephining  the 
cranium — Instruments  for — Precautions  in — Location  of  special  functions  of 
brain — Operations  on  supra-orbital  nerves — On  infra-orbital  nerves — On  supe- 
rior maxillary  nerves — On  inferior  dental  nerve — On  lingual  nerve — On  facial 
nerve — On  great  occipital  nerve — On  auricularis  magnus  nerve — On  spinal 
accessory  nerve — On  musculocutaneous  nerve — On  musculo-spiral  nerve — On 
median  nerve — On  radial  and  ulnar  nerves — On  great  sciatic  nerve— On  internal 
popliteal  nerves — On  external  popliteal  nerves — On  small  sciatic  nerves — On 
anterior  and  posterior  tibial  nerves — On  plantar  nerves — On  perineal  nerves — 
On  anterior  crural  nerve — On  long  saphenous  nerve — On  short  saphenous  nerve 
— Nerve  suturing — Nerve  transplantation  .         .         .         .         .         .         .         .134 

CHAPTER   VII. 

OPERATIONS   ON   TENDONS,    FASCIAE,    AND   MUSCLES. 

Instruments  for  tenotomy — Rules  for  tenotomy — Tenotomy  of  flexor  sublimis  and 
profundus  digitorum  muscles — Of  extensor  communis  digitorum — Of  extensor 
primi  internodii,  secundi  internodii,  and  ossis  mctacarpi  pollicis — Of  flexor  carpi 
radialis — Of  flexor  carpi  ulnaris — Of  biceps  of  forearm — Of  tibialis  posticus — 
Of  flexor  longus  digitorum  of  leg — Of  flexor  longus  pollicis  of  leg — Of  tendo 
Achillis — Of  peroneus  longus  and  brevis — Of  tibialis  anticus — Of  extensor  pro- 
prius  pollicis — Of  extensor  longus  digitorum — Of  peroneus  tertius — Of  biceps 
of  leg — Of  inner  hamstring  tendons  of  leg — Of  the  quadriceps  extensor  tendon 
— Of  pectineus — Of  adductor  longus — Of  tensor  vaginae  femoris — Of  sartorius — 
Of  multifidus  spinsc — Of  latissimus  dorsi — Of  erector  spinse — Of  sterno-cleido- 
mastoid — Of  the  plantar  fascia — Of  the  palmar  fascia — Dupuytren's  contraction 
— Tendon  suturing 151 

CHAPTER    VIII. 

OPERATIONS   ON   BONES. 

Gouging — Instruments  necessary  for — Sequcstrotomy — Instruments  necessary  for — 
Direct  method  of — Indirect  method  of— Excision — Time  of  operating — Instru- 


CONTEXTS. 


ments  necessary  for — Treatment  of  excision  wounds — Excision  of  the  upper 
jaw— Special  instruments  for— Complete  removal  of — Operation  by  median  in- 
cision— Excision  below  floor  of  orbit— Subperiosteal  excision  of — The  superior 
maxilla?  may  be  removed  simultaneously— Excision  of  the  inferior  maxilla- 
Excision  of  central  portion  of — Of  lateral  portion  of— Of  half  of— Of  entire 
bone — Of  the  alveolar  process  of — Operations  for  anchylosis  of — Excision  of 
the  sternum — Excision  of  a  portion  of  a  rib — Excision  of  the  clavicle — Ex- 
cisions of  the  scapula — Excisions  of  the  humerus — Excision  of  glenoid  angle 
of  scapula — Excisions  of  the  elbow-joint — Excision  of  the  ulna— Excision  of 
the  radius — Excisions  of  the  wrist-joint — Excision  of  the  lower  extremities— Of 
the  bones  of  the  forearm — Of  the  metacarpophalangeal  joints— Of  the  phalan- 
geal joints— Of  the  metatarso-phalangcal  joints— Of  the  metatarso-tarsal  joints 
Of  the  tarsal  joints — Excision  of  the  calcaneum — Of  the  astragalus — Excis- 
ions of  the  ankle-joint — Excision  of  the  bones  of  the  leg— Excisions  of  the 
knee-joint — Excision  of  the  patella — Of  the  great  trochanter — Excisions  of 
the  hip  -  joint— Excision  of  the  coccyx  —  Osteotomy — Instruments  employed 
for — Neck  of  femur,  sections  of— Supra-condyloid  osteotomy — Osteoarthrot- 
omy— Osteotomy  for  genu  varum— For  "bow-legs" — For  hallux  valgus— Os- 
teoplasty    1G1 

CHAPTER    IX. 

AMPUTATIONS. 

General  considerations— Care  in  making  flaps— Classification  of  flaps — Comparative 
merits  of  different  forms  of  flaps — Agents  required  for  an  amputation — Proper 
manner  of  holding  amputating  knife — Proper  manner  of  carrying  it  around  the 
limb — Proper  manner  of  using  the  saw — How  to  operate — Use  of  retractors — 
Amputations  at  the  phalangeal  articulations — Amputations  at  the  metacarpo- 
phalangeal articulations — Amputations  at  the  carpo-metacarpal  articulations — 
Amputations  through  the  metacarpal  bones — Amputations  at  the  wrist-joint — 
Amputations  at  the  elbow-joint — Amputations  of  the  forearm — Amputations  of 
the  arm — Amputations  at  the  shoulder-joint — Amputations  above  the  shoulder- 
joint  ........•••••• 


222 


CHAPTER   X. 

AMPUTATIONS    OF    TITE    LOWER    EXTREMITIES. 

\mputations  of  the  phalanges  in  their  continuity— Amputations  of  single  toes — Am- 
putations of  adjoining  toes — Amputation  of  toes  at  metatarso-phalangcal  joints 
— Amputation  through  metatarsal  bones — Amputation  of  great  toe,  with  its 
metatarsal  bone — Amputation  of  the  fifth  toe,  with  its  metatarsal  bone— Lis- 
franc's  amputation — Chopart's  amputation — Forbes'  modification  of  Chopart's 
amputation — Suh-astragaloid  disarticulation — Hancock's  amputation — Tripier's 
method— Mollierc's  method— Syme's  amputation— Modification  of  Syme's  opera- 
tion—Roux's  operation — Pirogoff's  amputation — Modifications  of  Pirogoffs  am- 
putation—I,o  Fort's  modification  of  Pirogoff's  amputation— Esmarch's  lifica- 

tion  of  Le  Fort's  operal ion— Mikulicz's  amputation— Supra-malleolar  amputa- 
tion— Amputations  at  the  lower  third  of  the  leg— Amputations  at  the  middle 
third  of  the  leg— Amputations  at  the  knee-joint — Amputations  through  the  con- 
dyle! of  (he  femur— Garden's  method — Grftti's  method— Stokos'  method— Ampu- 
taiions  of  the  thigh — Amputations  at  the  hip- joint 258 


X  CONTENTS. 

PAGE 

CHAPTER  XI. 

DEFORMITIES. 

Drisement  force — Barton's  operation  for  anchylosis — Curvature  of  the  spine — Plaster- 
of-Paris  jacket  for — Webbed  fingers,  treatment  for — Ingrown  nail — Ogston's 
treatment  of  flat-foot — Stokes'  treatment  of — Tarsectomy  .         .         .         .         .  297 

CHAPTER   XII. 

PLASTIC    SUEGEBY. 

Preparation  of  patient  for — Formation  of  flaps — Methods  of  transfer  of  flaps — Skin- 
grafting — Rhinoplasty — Mechanical  appliances  for  deformed  nose — Hare-lip — 
Cheiloplasty — Stomatoplasty — Staphyloplasty — Staphyloraphy — Uranoplasty — 
Elongated  uvula,  treatment  of 304 

CHAPTER  XIII. 

OPEBATIONS   ON    THE   MOUTH,    PHAEYNX,    AND   CESOPHAGUS. 

Salivary  fistula,  treatment  of — Excision  of  tonsils — Treatment  for  tongue-tie — For 
ranula — Excision  of  the  tongue — (Esophagotomy — Dilatation  of  the  oesophagus 
— (Esophagectomy — (Esophagostomy 335 

CHAPTER  XIV. 

OPEBATIONS   ON   HOLLOW   YISCEEA   IN   CONTACT   WITH   SEBOUS   SUEFACES. 

Indications  to  be  met — Forms  of  sutures  employed  for  sewing  serous  surfaces — 
Gastrostomy — Gastrotomy — Gastroenterostomy — Duodenostomy — Jejunostomy 
— Resection  of  the  pylorus — Cholecystotomy — Cholecystectomy — Laparotomy — 
Enterotomy — Enterectomy — Colotomy — Iliac  abscess,  operation  for — Artificial 
anus,  treatment  for — Nephrotomy — Nephrectomy — Nephrolithotomy — Nephror- 
raphy  —  Splenectomy — Paracentesis  abdominis  —  Hernia  —  Radical  cure  of — 
Kclotomy 348 

CHAPTER   XV. 

OPERATIONS    ON   THE   ANUS    AND   RECTUM. 

Examination  of  anus — Operation  for  imperforate  anus — For  absence  of  anus — For 
fistula  in  ano — Surgical  anatomy  of  rectum — Operations  for  prolapsus  ani — For 
cancer  of  rectum — For  stricture  of  rectum — For  imperforate  rectum  .         .         .  401 

CHAPTER   XVI. 

OPERATIONS   ON   THE   UEINAEY   BLADDEE. 

Introduction  of  a  catheter  or  sound  into  the  bladder— Introduction  of  whalebone 
guides — Aspiration  of  bladder — Cystotomy — Digital  exploration  of  bladder — 
Treatment  of  extroversion  of  bladder — Puncturing  bladder — Lithotrity — Litho- 
lapaxy — Lithotomy 416 

CHAPTER    XVII. 

OPERATIONS    ON   THE   PENIS   AND   SCROTUM. 

Operations  for  hydrocele— Castration— Circumcision— Treatment  of  paraphymosis — 
Methods  of  amputation  of  penis — Extirpation  of  penis — Operations  for  hypo- 


CONTEXTS.  xj 

PAGE 

spadias — Operations  for  epispadias —  Urethroraphy — Urethroplasty — External 
perineal  urethrotomy — Internal  urethrotomy — Tapping  the  urethra    .         .         .  455 

CHAPTER   XVIII. 

MISCELLANEOUS    OPEKATIOXS. 

Tapping  the  pericardium — Extirpation  of  the  breast — Extirpation  of  the  axillary 
glands — Extirpation  of  the  parotid  gland — Paracentesis  thoracis — Perforation  of 
the  antrum — Plugging  posterior  nares— Removal  of  nasal  polypi — Removal  of 
naso-pharyngeal  polypi — Deviation  of  the  septum  nasi,  operations  for — Laryn- 
gotomy — Tracheotomy — Laryngo-traeheotomy — Intubation  of  the  larynx — Phar- 
yn.sotomy — Laryngectomy — Removal  of  goitre — Artbrectomy — Wiring  patella 
— Movable  bodies  in  joints,  operation  for — Ganglion,  operations  for — Wiring  of 
bones  for  compound  fractures    ..........  479 


ILLUSTRATIONS. 


PAGE 

Abdominal  sections,  location  of  incisions  for.     Fig.  563.  Original.     Zb-i 

Acupressure.     Figs.  45-4T.  Thomas  Bryant.       32 

Allingham's  screw  crushing  instrument  for  hemorrhoids.    Fig.  WO. 

Caswell,  Hazard  &  Co.,  W.  F.  Ford,  N.  Y.     120 
Amputating  knife,  how  to  grasp.     Fig.  315.  Original.     231 

Amputating  knife,  how  to  carry  around  limb.     FL'.  316.  Original.     232 

Amputating  knife,  how  to  carry  around  limb,  another  method.  Fijr.  317.  S.  Smith.  232 
Amputating  knife,  how  carried  around  limb,  a  common  method.  Fig.  318.  Esmarch.  232 
Amputation,  catching  bleeding  points.     Fig.  327.  Packard.     234 

Amputation  by  circular  method.     Fig.  303.  Esmarch.     2'J4 

Amputation  by  circular  method,  dissecting  up  flap.     Fig.  304.  Esmarch.     2U5 

Amputation  by  circular  method,  dissecting  up  flap,  how  not  to  do  it.  Fig.  305.  Esmarch.  225 
Amputation  by  circular  method,  circular  division  of  muscles.     Fig.  306.  Esmarch.     226 

Amputation,  circular  method,  sawing  the  bon^.     Fig.  324.  Ashhurst,  modified.     234 

Amputation,  circular,  stump  after.     Fig.  307.  Esmarch.     226 

Amputation,  circular,  modified.     Fig.  308.  Ashhurst.     227 

Amputation,  equilateral  flaps.     Fig.  313.  Esmarch.     22'.) 

Amputation,  Hancock's.     Figs.  402,  403.  Esmarch.     266 

Amputation,  periosteal  flap.     Figs.  425,  427.  Original.     274,  275 

Amputation,  rectangular  flap.     Figs.  311,  312.  Gross.     229 

Amputation,  sawing  the  bone.     Fig.  324.  Ashhurst,  modifkd.     234 

Amputation,  Teale's  method.     Figs.  311,  312.  Gross.     229 

Amputation,  flap  by  transfixion.     Figs.  309,  310.  Gross.     228 

Amputation,  De  Liraerolles'.     Figs.  398-403.  Esmarch.     264-266 

Amputation  at  medio-tarsal  articulation,  Chopart's.     Fir.  386.  Kew.     260 

Amputation  at  medio-tarsal  articulation,  Chopart's.     Figs.  392-397.  Esmarch.     262-264 

Amputation  at  metatarso-phalangeal  articulation,  square-flap  method,  of  all  the  toes. 

Figs.  380-383.     Esmarch.     258,  259 
Amputation,  sub-a-tragaloid.     Fitrs.  398-403.  Esmarch.     264-266 

Amputation,  Bub-astragaloid,  De  Lignerollcs'.     Figs.  398-401,  403.  Esmarch.     264-266 

Anaesthetics,  administering,  drawing  the  tongue  forward.     Fig.  9.  Esmarch.      13 

Anesthetics,  administering,  pressing  the  jaw  forward.    Fig.  10.  Esmarch.      14 

Anchylosis,  bony,  Barton's  operation  for.     Fig.  461.  Gross.     298 

Aneurism  needle  and  director  combined.    Fig.  97.  G,  II.  <&  Co.,  Ford.      59 

Aneurism  needle,  Fletcher's.     Fig.  100.  G,  ff.  dk  Go.,  Ford.      60 

Aneurism  needle,  Mott's.     Fig.  99.  C,  II.  <&  Co.,  Ford.      60 

Aneurism  needle,  Byrne's.     Fig.  98.  G,  II-  db  Co.,  Ford.      60 

Fig.  100.  G,  II.  <(•  Go.,  I<>rd.       80 

Ankle-joint,  disarticulation  at  the.     Figs.  404-409,  413-415,  417-424. 

A.  march.    267,  268,  270,  271-273 
Ankle-joint,  disarticulation  at  the.     Fig.  410.  Griginul.    269 

Ankle-joint,  amputation  at,  modification  of  Byrne's.     Fig.  410.  Original.    269 

Ankle-joint,  amputation  at,  removal  of  the  i  ntire  foot,  Byrne's.    Figs.  101-409. 

Esmarch.     267,208 


XIV 


ILLUSTRATIONS. 


577. 
Fig.  101. 


Fur.  161. 


Ankle-joint,  amputation  at,  Eoux's.     Figs.  411,  412. 

Ankle-joint,  amputation  at,  Esmarch's.     Figs.  421-424. 

Ankle-joint,  amputation  at,  Brans'.     Fig.  420. 

Ankle-joint,  excision  of,  internal  incisions.     Fig.  275. 

Ankle-joint,  excision  of,  removal  of  lower  end  of  fibula.     Fig.  274. 

Ankle-joint,  excision  of.     Fig.  272. 

Ankle-joint,  anatomy  of.      Fig.  273. 

Ankle-joint,  anatomy  of,  inner  side.     Fig.  276. 

Ankle-joint,  amputation  at,  Pirogoff's.     Figs.  413-415 

Ankle-joint,  amputation  at,  Pirogoff's.     Fig.  416. 

Ankle-joint,  amputation  at,  Pirogoff's.     Fig.  417. 

Ankle-joint,  amputation  at,  Le  Fort's.     Figs.  418-419. 

Anklets  and  wristlets,  Pritchard's.     Fig.  695. 

Antiseptic  adhesive  plaster  between  sutures,     hig.  77. 

Antiseptic  dressing  in  position.     Fig.  90. 

Antiseptic  spray  apparatus,  Wen's.     Fig.  89. 

Anus,  absence  of.     Fig.  619. 

Anus,  artificial,  cnterotome  applied.     Fig 

Aorta,  abdominal,  and  inferior  vena  cava. 

Aponeurotome.     Fig.  711. 

Arch,  palmar,  superficial  linear  guide  to. 

Arm,  amputation  of,  Langenbcck.     Fig.  364. 

Arm,  amputation  of,  by  long  anterior  flap.     Fig.  366. 

Arm,  amputation  of,  by  unequal  skin-flax'&.     Fig.  365. 

Arteries,  femoral,  deep  and  superficial,  relations  of.     Fig.  122. 

Arteries,  iliac,  linear  guides  to.    Fig.  102. 

Arteries,  iliac,  venous  relations  of.     Fig.  103. 

Arteries,  iliac,  venous  relations  of.     Fig.  103. 

Arteries,  ligature  of,  opening  sheath  of  vessel.     Fig.  92. 

Arteries,  ligature  of,  passing  aneurism  needle.     Fig.  93. 

Arteries,  ligature  of,  passing  probe.    Fig.  94. 

Arteries,  ligature  of,  primary  incision.     Fig.  91. 

Arteries  of  neck,  linear  guide.    Fig.  136. 

Arteries  of  neck  and  face,  linear  guide.     Fig.  137. 

Artery,  abdominal  aorta  and  inferior  vena  cava.     Fig.  lol. 

Artery,  axillary,  ligature  of  first  portion.     Fig.  141. 

Artery,  axillary,  ligature  of  first  portion.     Fig.  142. 

Artery,  axillary,  ligature  of  third  portion.     Fig.  144. 

Artery,  axillary,  linear  guide  to  third  portion.     Fig.  143. 

Artery,  brachial,  digital  compression  of.     Fig.  38. 

Artery,  brachial,  ligature  of,  in  middle  third.     Fig.  146. 

Artery,  brachial,  ligature  of,  in  middle  third.     Fig.  147. 

Artery,  brachial,  tourniquet  applied.     Fig.  41. 

Artery,  brachial,  ligature  of,  in  lower  third.     Fig.  148. 

Artery,  brachial,  ligature  of,  in  lower  third.     Fig.  149. 

Artery,  brachial,  linear  guide  to.     Fig.  145. 

Artery,  carotid,  common,  ligature  of.     Fig.  164. 

Artery,  carotid,  common,  ligature  of,  below  omo-hyoid  muscle 

Artery,  carotid,  common,  surgical  anatomy  of.     Fig.  162. 

Artery,  carotid,  external,  surgical  anatomy  of.     Fig.  165. 

Artery  compressor,  Gross'.     Fig.  57. 

Artery  compressor,  Milne's.     Fig.  58. 

Artery  compressor,  Speir's.     Fig.  61. 

Artery,  dorsalis  pedis.     Fig.  130. 

Artery,  dorsalis  pedis,  ligature  of.     Fig.  131. 

Artery,  dorsalis  pedis,  linear  guide  to.     Fig.  126. 

Artery,  epigastric,  linear  guide  to.     Fig.  111. 

Artery,  epigastric,  course  of.     Fig.  610. 


PAGE 

Gross. 

270 

Esmarch. 

273 

Esmarch. 

272 

Esmarch. 

201 

Hsmarch. 

200 

Esmarch. 

199 

Esmarch. 

200 

Esmarch. 

201 

Esmarch.     270 

,271 

S.  Smith. 

271 

Esmarch. 

271 

Esmarch. 

272 

C,  H.  &  Co.,  Ford. 

443 

Esmarch. 

43 

B.  A.  Watson. 

50 

C.,H.&  Co.,  Ford. 

48 

Gross. 

403 

Packard. 

373 

Sedillot. 

61 

C,  II.  &  Co.,  Ford. 

453 

Gross. 

106 

Esmarch. 

249 

Esmarch. 

250 

Esmarch. 

249 

Gray. 

77 

Stimscn,  modified. 

61 

Seditlot. 

62 

Sedillot. 

62 

Gross. 

58 

Esmarch. 

58 

Esmarch. 

58 

Packard. 

57 

Stimson,  modified. 

86 

Original. 

89 

Sedillot. 

61 

Sedillot. 

96 

Mott. 

97 

Sedillot. 

98 

New. 

97 

Esmarcli. 

28 

Sedillot. 

99 

Mott. 

100 

Esmarch. 

29 

Sedillot. 

100 

Mott. 

100 

J\'eu\ 

.  98 

Mott. 

108 

ig.  163.         Sedillot. 

108 

Sedillot. 

106 

Sedillot. 

10S 

G,  II.  c&  Co.,  Ford. 

34 

C,  II.  d;  Co.,  Ford. 

35 

C.,  II.  <&  Co.,  Ford. 

35 

Packard. 

81 

.    Sedillot. 

82 

Stimson,  modified. 

79 

Stimson,  modified. 

70 

Gray. 

396 

ILLUSTRATIONS. 


XV 


Artery,  facial,  ligature  of.    Fig.  168. 

Artery,  femoral,  compression  of,  digital.     Fig.  37. 

Artery,  femoral,  ligature  of,  at  apex  of  Scarpa's  triangle.     Fig.  11 

Artery,  femoral,  ligature  of,  at  apex  of  Scarpa's  triangle.     Fig.  11 

Artery,  femoral,  ligature  of,  in  Hunter's  canal.     Fig.  120. 

Artery,  femoral,  ligature  of,  in  Hunter's  canal.     Fig.  121. 

Artery,  femoral,  ligature  of,  in  upper  third.     Fig.  116. 

Artery,  femoral,  linear  guide  to.     Figs.  111-114. 

Artery,  femoral,  relations  of.     Fig.  115. 

Artery,  femoral,  relations  of.     Fig.  117. 

Artery,  femoral,  tourniquet  applied  to.     Fig.  40. 

Artery,  gluteal,  ligature  of.     Fig.  107. 

Artery,  gluteal,  linear  guide  to.     Fig.  106. 

Artery,  iliac,  common,  incision  for  ligaturing.     Fig.  104. 

Artery,  iliac,  external,  ligature  of.     Fig.  112. 

Artery,  iliac,  external,  ligature  of.     Fig.  113. 

Artery,  iliac,  external,  linear,  guide  to.     Fig.  111. 

Artery,  iliac,  primitive,  ligature  of.     Fig.  105. 

Artery,  lingual,  ligature  of.     Fig.  166. 

Artery,  lingual,  surgical  anatomy  of.     Fig.  167. 

Artery,  obturator,  course  of.     Fig.  614. 

Artery,  occipital,  ligature  of.     Fig.  16'J. 

Artery,  popliteal,  ligature  of,  at  lower  third.     Fig.  125. 

Artery,  popliteal,  ligature  of,  at  upper  third.     Fig.  124. 

Artery,  popliteal,  linear  guide  to.     Fig.  123. 

Artery,  pudic,  linear  guide  to.     Fig.  109. 

Artery,  pudic,  passing  needle  around.     Fig.  110. 

Artery,  radial,  ligature  of,  at  apex  of  styloid  process.     Fig.  155. 

Artery,  radial,  ligature  of,  at  lower  third.     Fisr.  153. 

Artery,  radial,  ligature  of,  at  lower  third. 

Artery,  radial,  ligature  of,  at  upper  third. 

Artery,  radial,  ligature  of,  at  upper  third. 

Artery,  radial,  linear  guide  to.     Fie;.  150. 

Artery,  sciatic,  ligature  of.     Fig.  108. 

Artery,  sciatic,  linear  guide  to.     Fig.  106. 

Artery,  subclavian,  ligature  of  third  portion.     Fig.  139. 

Artery,  subclavian,  ligature  of  third  portion.     Fig.  140. 


PAOK 

Sedillot.     116 

Esmareh.       28 

Sedillot. 

Molt. 
Sedillot. 
Mott,  modified. 
S.  Smith. 


Fig.  154. 
Fig.  151. 

Fig.  152. 


Artery,  subclavian,  surgical  anatomy  of.     Fig.  138. 

Artery,  temporal,  ligature  of.     Fig.  168. 

Artery,  torsion  of  an.     Fig.  49. 

Artery,  tibial,  anterior,  ligature  of,  at  middle  third.     Fig.  129. 

Artery,  tibial,  anterior,  linear  guide  to.     Fig.  126. 

Artery,  tibial,  posterior,  ligature  of,  at  lower  third.     Fig.  135. 

Artery,  tibial,  posterior,  ligature  of,  at  middle  third.     Fig.  133. 

Artery,  tibial,  posterior,  ligature  of.  at  middle  third.     Fig.  184. 

Artery,  tibial,  posterior,  linear  guide  to.     Fig.  132. 

Artery,  ulnar,  ligature  of,  at  junction  of  middle  and  upper  thirds. 

Artery,  ulnar,  ligature  of,  at  junction  of  middle  and  uppor  thirds. 

Artery,  ulnar,  ligature  of.  at  lower  third.     Fig.  158. 

Artery,  ulnar,  ligature  of,  at  lower  third.     Fig.  159. 

Artery,  ulnar,  ligature  of,  at  wrist.      Kg.  160. 

Artery,  ulnar,  linear  guide  to.     Fig.  150. 

Aspirator,  Fitch's.     Fig.  581. 

A  pirator,  trachea.     Fig.  1M. 

Aspirator,  Potein's.     Fi 

Atomizer,  Richard  on'*.     Fig.  14. 


Stimson,  modified.     70-72 

Sedillot.  73 

Gray.  74 

Esmareh.  29 

S.  Smith.  67 

Stimson,  modified.  66 

Otis,  modified.  63 

/S.  Smith.  70 

Mott.  70 

Stimson,  modified.  70 

Otis,  modified.  64 

Sedillot.  114 

Esmareh,  modified.  114 

Gray.  400 

Sedillot.  117 

S.  Smith.  79 

Sedillot.  7b 

New.  78 

S.  Smith.  68 

£'.  Smith.  68 

Sedillot.  103 

Sedillot.  103 

Mott.  103 

Sedillot.  102 

Mott.  102 

Stimson,  modified.  101 

6'.  Smith,  67 

Stimson,  modified.  66 

Sedillot.  91 

Mott.  91 

Sedillot.  90 

Sedillot.  1 1  6 

Esmareh.  33 

Sedillot.  81 

Stimson,  modified.  79 

Sedillot.  84 

Sedillot.  84 

Mott.  84 

Stimson,  modified.  83 

Fitr.  156.     Sedillot.  104 

Fig.  157.         Molt.  104 

Sedillot.  105 

Mott.  106 

Sedillot.  105 

Stimson,  modified.  101 

0.,  //.  db  Co.,  Ford.  37k 

C,  IF.  <t  Co.,  Ford,  m 

01,  //.  ,(■  0b.,  Ford.  «78 

C,  II.  <(■  Co  .  Ford.  17 


Band,  corn  pi 


I i..       25 


XVI 


ILLUSTRATIONS. 


PAGE 

Bandage,  clastic.     Fig.  27.  Esmarch.  24 

Bandage,  elastic,  applied.     Fig.  23.  Esmarch.  25 

Bandage,  rubber,  Martin's.     Fig.  33.  C,  II.  &  Co.,  Ford.  27 

Bistouri  cache,  Civiale's.    Fig.  747.  C,  H.  &  Co.,  Ford.  475 

Bistouries  and  scalpels.    Fig.  15.  C,  H.  &  Co.,  Ford.  18 

Bistoury,  beaked,  Gouley's.     Fig.  741.  C,  H.  &  Co.,  Ford.  471 

Bladder,  evacuating  apparatus  or  washer,  Bigclow's.     Fig.  670.  C,  II.  &  Co.,  Ford.  432 

Bladder,  evacuating  apparatus  or  washer,  Otis'.     Figs.  671,  672.  C,  H.  &  Co.,  Ford.  433 

Bladder,  evacuating  apparatus  or  washer,  Thompson's.    Fig.  609.  C,  H.  &  Co.,  Ford.  432 

Bladder,  extroversion  of  the,  Bigelow's  operation.     Fig.  651.  S.Smith.  424 

Bladder,  extroversion  of  the,  Bigelow's  operation.     Fig.  652.  Agnew.  424 

Bladder,  extroversion  of  the,  Maury's  operation.     Fig.  650.  S.  Smith,  modified.  423 

Bladder,  extroversion  of  the,  Wood's  operation.     Figs.  653,  654.  Gross.  425 

Bladder,  puncturing  the.     Fig.  657.  Bumstead  &  Taylor.  426 

Blow-pipe.     Fig.  64.  C,  H.  &  Co.,  Ford.  36 

Bone  pliers,  Butcher's.    Fig.  487.  C,  II.  &  Co.,  Ford.  316 

Bougies  a  boulc,  Otis'.    Fig.  745.  C,  H.  &  Co.,  Ford.  475 

Bougies,  filiform.     Fig.  646.  C,  H.  &  Co.,  Ford.  420 

Bougies,  non-metallic.    Fig.  746.  C,  II.  &  Co.,  Ford.  475 

Breast,  removal  of  the.     Fig.  753,  754.  S.Smith.  479 

Breast,  removal  of  the,  incisions  for.     Fig.  755.  Gross,  modified.  480 

Buck's  needle  conductor.     Fig.  48.  C,  II.  &  Co.,  Ford.  32 

Bunion,  with  hallux  valgus.     Fiy.  468.  Gross.  302 


Canal,  femoral,  location  of.     Fig.  612. 

Oanula,  Bcllocq's.     Fig.  757. 

Canuia,  polypus,  nasal.     Fig.  760. 

Capillaries,  subcutaneous  ligaturing  of.     Figs.  189-194. 

Carpo-metacarpal  articulation,  amputations  at.     Figs.  341-345. 

Carpus,  ligaments  of  dorsal  surface  of.     Fig.  266. 

Carpus,  ligaments  of  palmar  surface  of.     Fig.  267. 

Carpus,  synovial  membranes  of.     .tig.  265. 

Catheter,  chemise.     Fig.  694. 

Catheter,  double-elbowed,  Mercier's.     Fig.  636. 

Catheter,  elbowed,  Mercier's.     Fig.  637. 

Catheter,  evacuating,  Bigelow's.    Fig.  673. 

Catheter,  evacuating,  spiral-tipped,  Warren's.     Fig.  674. 

Catheter,  evacuating  and  lithotiite  combined,  author's.     Fig.  677 

Catheter-guide,  Keyes'.     Fig.  640. 

Catheter-guide,  Otis'.    Fig.  641. 

Catheter,  olivary  gum.     Fig.  642. 

Catheter,  passing  a.    Fig.  644. 

Catheter  entering  bladder.     Fig.  645. 

Catheter,  self-retaining.     Fig.  638. 

Catheter,  self-retaining,  Holt's.    Fig.  639. 

Catheter,  velvet-eye.    Fig.  643. 

Catheter,  tunneled,  and  guide,  Gouley's.     Fig.  649,  742. 

Catlin.     Fig.  321. 

Cautery-irons.     Fig.  63. 

Cautery,  thermo,  Paquelin's.     Fig.  65. 

Cheek-compressor  for  hare-lip,  Hainsley's.     Fig.  496. 

Chisel.     Fig.  225. 

Chisels.     Fig.  292. 

Chciloplasty,  lower  lip,  Celsus'  method.     Fig.  498. 

Cheiloplasty,  lower  lip,  Celsus'  method.     Fig.  499. 

Cheiloplasty,  lower  lip,  contracted.  Buck's  method.     Figs.  502,  503 

Cheiloplasty,  lower  lip,  horizontal  incision.     Fig.  500. 

Cheiloplasty,  lower  lip,  Malgaignc's  method.     Fig.  504. 


Gray.  398 

C,  H.<&  Co.,  Ford.  484 

C,  E.  &  Co.,  Ford.  485 

S.  Smith.  133 

Esmarch.     240,  241 

Esmarch.  194 

Esmarch.  194 

Esmarch.  193 

C.,H.  &  Co.,  Ford.  443 

C.,H.<&  Co.,  Ford.  416 

C.,H.&  Co.,  Ford.  416 

C.,H.&  Co.,  Ford.  433 

C.,H.&  Co.,  Ford.  434 

C.,H.&  Co.,  Ford.  436 

C.,H.&  Co.,  Ford.  417 

C.,H.&  Co.,  Ford.  417 

C,  JET.  &  Co.,  Ford.  417 

Bumstead  &  Taylor.  41 7 

Bumstead  <&  Taylor.  419 

C.,H.  &  Co.,  Ford.  416 

C.,H.&  Co.,  Ford.  416 

C,  H.  &  Co.,  Ford.  417 

C  ,  H.  &  Co.,  Ford.  421 

C..H.&  Co.,  Ford.  233 

C.,H.&  Co.,  Ford.  36 

C,  H.  &  Co.,  Ford.  36 

Gross.  820 

C.,  H.  &  Co.,  Ford.  162 

C.,H.&  Co.,  Ford.  215 

New.  320 

Stimson,  modified.  321 

Buck.     322,  323 

Stimson.  321 

Stimson.  324 


ILLUSTRATIONS. 


XVll 


Cheiloplasty,  lower  lip,  operation  by  V-shaped  incision.     Fi^j.  497. 
Cheiloplasty,  lower  lip,  Sedillot's  method.     Fig.  505. 
Cheiloplasty,  Byrne' s  method.     Fig.  501. 

Cheiloplasty,  upper  lip,  Dieffenbach's  method.     Figs.  508,  509. 
Cheiloplasty,  upper  lip,  Buck's  method.     Figs.  506,  50%. 
Cheiloplasty,  upper  lip,  Sedillot's  vertical-flap  method.     Figs.  510, 

Chloroform  inhaler,  Esmareh's.     Fig.  1. 

Clamp,  bandage,  Lang-en  beck's.     Fig.  32. 

Clamp,  Bodenhamer's.     Fig.  729. 

Clamp,  scrotal,  Henry's.     Fig.  173. 

Clamps,  nasal  septum,  Adams'.     Fig.  771. 

Collins'  transfusion  instrument.     Fig.  1S5. 

Colon,  ascending,  surgical  relations  of.     Fig.  572. 

Colon,  descending,  surgical  relations  of.     Fig.  571. 

Colotomy,  left  lumbar.     Figs.  573-575. 

Colotomy,  left  lumbar.     Fig.  576. 

Colotomy,  left  lumbar  (Amussat),  linear  guide  to  colon.    Fig.  570. 

Compress,  conical.     Fig.  36. 

Compress,  oblong     Fig.  35. 

Compress,  pyramidal.     Fig.  34. 

Crutch,  Clover's,  applied.     Fig.  696. 

Dilator,  Dolbeau's.     Figs.  032,  633. 

Dilators,  oesophageal.     Fig.  547. 

Dilator,  trachea,  Chassaignac's.     Fig.  780. 

Dilator,  trachea,  Trousseau' s.     Fig.  779. 

Dilator,  urethral,  Gross'.     Fig.  714. 

Director,  Allingham's.     Fig.  629. 

Director,  grooved.     Fig.  24. 

Director,  grooved,  and  aneurism  needle  combined.     Fig.  97. 

Director,  hernial,  Levis'.     Fig.  603. 

Double  hook,  Langenbeck's.     Fig.  778. 

Drainage,  spiral,  Ellis'.     Fig.  87. 

Drainage-tube,  rubber.     Fig.  88. 

Drill,  bone,  French.     Fig.  791. 

Eibow-joint,  amputation  at.     Fig.  360. 

Elbow-joint,  amputation  at,  circular.     Fig.  361. 

Elbow-joint,  amputation  at,  single-flap.     Fig.  362. 

Elbow-joint,  disarticulation  at.     Figs.  360,  361. 

Elbow-joint,  disarticulation  at.     Figs.  362,  363. 

Elbow-joint,  excision  of,  Hiiter.     Fig.  259. 

Elbow-joint,  excision  of,  exposing  internal  condyle.     Fig.  263. 

Elbow-joint,  excision  of,  Langenbeck.     Fig.  261. 

Elbow-joint,  excision  of,  Liston.     Fig.  262. 

Eibow-joint,  ligaments  of.    Fig.  260. 

Elbow-joint,  relations  of  ulnar  nerve  to.     Fig.  258. 

Elevator.     Figs.  198-200. 

Enterectomy,  Treves'  apparatus  for.     Fig.  569. 

Epispadias,  ftelaton's  operation  for.     Pigs.  784,  7:'..r>. 

Epispadias,  Thiersch's  operation  for.    Fig.  736,  737. 

Ether  inhaler,  Alii.-,'.      Figs.  .'!,  4. 

inhaler,  cloth  and  paper.    Fig.  2. 

inhaler,  Clover's.     Fig.  6. 
Ether  inhaler,  Lente'i  modified.     Fig.  5. 
Ether  Inhaler,  Noyes'.    Fig.  8. 

inhaler,  Squibb's.     Fig.  7. 

inal,  apparatus  tor.     Fig.  13. 


PAOE 

Stimson. 

320 

Stimson. 

324 

New. 

322 

A  (/new. 

326 

Buck.     324 

,  325 

511. 

Stimson,  modified. 

326 

Esmarch. 

6 

a. 

II.  &  Co.,  Ford. 

26 

a, 

H.  <&  Co.,  Ford. 

462 

a. 

,  H.  db  Co.,  Ford. 

122 

6'., 

II.  db  Co.,  Ford. 

492 

Esmarch. 

129 

Treves. 

370 

Treves. 

369 

Original. 

371 

Packard. 

372 

.S. 

Smith,  modified. 

367 

Esmarch. 

27 

Esmarch. 

27 

Esmarch. 

27 

Original. 

444 

a. 

,  II.  db  Co.,  Ford. 

440 

c. 

,  H.  &  Co.,  Ford. 

345 

a, 

H.  db  Co.,  Ford. 

495 

c. 

,  H.  db  Co.,  Ford. 

495 

c, 

,  H.  db  Co.,  Ford. 

454 

a, 

II.  &  Co.,  Ford. 

407 

c. 

,  H.  &  Co.,  Ford. 

20 

a, 

II.  &  Co.,  Ford. 

59 

c, 

II.  db  Co.,  Ford. 

392 

a, 

II.  d<  Co.,  Ford. 

495 

a, 

II.  db  Co.,  Ford. 

46 

c, 

II.  db  Co.,  Ford. 

46 

c, 

II.  db  Co.,  Ford. 

509 

Esmarch. 

247 

Esmarch. 

247 

S.  Smith. 

243 

Esmarch. 

247 

S.  Smith. 

248 

Esmarch. 

189 

Esmarch. 

189 

Esmarch. 

189 

Esmarch. 

189 

Esmarch. 

189 

Esmarch. 

188 

a, 

11.  <(•  Co.,  Ford. 

136 

Treves. 

806 

New. 

467 

Stimson. 

468 

Heath, 

7 

Original. 

7 

c. 

11.  <(•  Co.,  Ford. 

9 

a, 

ll.  db  Co.,  Fori. 

9 

a, 

II.  db  Co.,  Ford. 

11 

a, 

II.  ,<■  Co.,  Ford. 

10 

a, 

ll.  db  '•„.,  Ford. 

17 

XV1I1 


ILLUSTRATIONS. 


Fascial  contractions.     Fig.  221. 

Fascia]  contractions,  Dupuytren's  incisions  for.     Fig.  222. 
Fascia,  nicking.     Fig.  23. 
Fasciatome.     Fig.  219. 

Femur,  subcutaneous  division  of  neck  of,  Adams'.     Fig.  293. 
Femur,  subcutaneous  division  of  neck  of,  Sayre's  lines  of  section. 
Femur,  subcutaneous  division  of  nerk  of,  Volkmann's.     Fig.  29." 
Flexor  tendons  of  fingers,  linear  guide  to.     Fig.  161. 
Fingers,  amputations  of.     Figs.  333-340. 
Fistula  in  ano.     Fig.  621. 
.  Fistula  in  ano,  dividing  fistulas.     Figs.  626-628. 
Fistula  in  ano,  probing  a  fistula.     Fig.  622. 
Fistula  in  ano,  variations  in.     Figs.  623,  624. 
Fistula,  fecal,  enterotcme  applied.     Fig.  577. 
Fistula,  salivary,  Horner's  operation.     Fig.  537. 
Fistula,  salivary,  scton  in  position.     Fig.  536. 
Forceps,  artery,  Hamilton's  (F.  H.).     Fig.  52. 
Forceps,  artery,  and  needle-holder  combined.     Fig.  76. 
Forceps,  artery,  spring-catch,  fenestrated,  Listen's,     Fig.  51. 
Forceps,  bone-cutting,  curved,  Listen's.     Figs.  228,  229. 
Forceps,  bone-cutting,  straight,  Listen's.     Fig.  227. 
Forceps,  bone-holding,  Faraboeuf's.     Figs.  238,  326.  C, 

Forceps,  bone-holding,  Ferguson's.     Fig.  238. 
Forceps,  bone-holding,  Langenbeck's.     Fig.  238. 
Forceps,  cross-bar  (hemostatic).     Fig.  566. 
Forceps,  gouge,  Hoffman's.     Fig.  207. 
Forceps,  lion-jaw,  Ferguson's.     Fig.  325. 
Forceps,  lithotomy,  curved.     Fig.  090. 
Forceps,  lithotomy,  straight.     Fig.  689. 
Forceps,  mouse-tooth,  Listen's.     Fig.  53. 
Forceps,  needle,  Gross'.     Fig.  533. 
Forceps,  needle,  Prout's.     Fig.  74. 
Forceps,  needle,  Sands'.     Fig.  75. 
Forceps,  needle,  Stimson's.     Fig.  73. 
Forceps,  phymosis,  Fisher's.     Fig.  718. 
Forceps,  phymosis,  Henry's.     Fig.  717. 
Forceps,  polypus,  nasal,  curved.     Fig.  758. 
Forceps,  polypus,  nasal,  straight.     Fig.  759. 
Forceps,  rectal,  Byrnes'.     Fig.  620. 
Forceps,  rhinoplastos,  Adams'.     Fig.  770. 
Forceps,  sequestrum,  Ferguson's.     Fig.  203. 
Forceps,  sequestrum,  Van  Burcn's.     Fig.  202. 
Forceps,  serrefine.     Fig.  54. 
Forceps,  tenaculum,  Prince's.     Fig.  62. 
Forceps,  throat,  Burge's.    Fig.  553. 
Forceps,  throat,  Cusco's.     Fig.  552. 
Forceps,  throat,  Mathieu's.     Fig.  551. 
Forceps,  thumb.     Fig.  22. 
Forceps,  torsion,  Hcwson's.     Fig.  50. 
Forceps,  trachea.     Fig.  785. 
Forceps,  wire-twisting,  Sims'.     Fig.  525. 
F'oulis'  fastening  (for  clastic  bandage)  in  position.     Fig.  30. 
Foulis'  fastening  (for  elastic  bandage)  with  rubber  cord.     Fig.  31. 


PARE 

Albe.  160 

Abbe.  160 

Esmarch.  20 

C.,  II.  &  Co.,  Ford.  152 

Gross.  216 

Fig.  294.         Gross.  217 

Poore,  218 

Gt'oss.  106 

Esmarch.     238-240 

Van  Buren.  404 

S.  Smith.  406 

Packard.  405 

Van  Buren.  405 

Packard.  373 

Packard.  336 

Gross.  336 

C,  II.  &  Co.,  Ford.  34 

C,  U.  &  Co.,  Ford.  43 

C,  II.  &  Co.,  Ford.  33 

C,  H.  &  Co.,  Ford.  163 

C,  H.  &  Co.,  Ford.  163 

H.  <£•  Co.,  Ford.     168,  234 

C,  H.  &  Co.,  Ford.  168 

C.,H.&  Co.,  Ford.  168 

C,  II.  &  Co.,  Ford.  358 

C.,  If.  &  Co.,  Ford.  137 

C,  H.  tt-  Co.,  Ford.  234 

C,  H.  eft  Co.,  Ford.  442 

C,  II..  eft  Co.,  Ford.  442 

C,  H.  cC-  Co.,  Ford.  34 

<?.,  H.  &  Co.,  Ford.  332 

V.,  II.  &  Co.,  Ford.  42 

C,  H.  &  Co.,  Ford.  42 

C,  H.  eft  Co.,  Ford,  42 

6'.,  H.  eft  Co.,  Ford,  458 

V.,  H.  cfr  Co.,  Ford.  458 

a,  H.  <C-  Co.,  Ford.  485 

C,  H.  &  Co.,  Ford.  486 

C,  H.  &  Co.,  Ford.  404 

€.,  II.  &  Co.,  Ford.  491 

C.,H.  &  Co.,  Ford.  137 

C,  H.  &  Co.,  Ford.  137 

C,  H.  &  Co.,  Ford.  34 

C,  H.  &  Co.,  Ford.  35 

C.  H.  &  Co.,  Ford.  348 

C,  H.  &  Co.,  Ford,  347 

C,  H.  tC-  Co.,  Ford.  347 

C,  H.  &  Co.,  Ford.  20 

C,  H.  &  Co.,  Ford.  33 

C,  H.  &  Co.,  Ford.  497 

C,  H.  &  Co.,  Ford.  329 

Esmarch.  26 

Esmarch.  26 


Gastroenterostomy.     Fig.  565. 
Gastrostomy,  needles  in  position.     Fig.  564. 
Genu  valgum.     Fig.  236. 
Genu  valgum,  Macewcn's  line  of  bone  section. 


Fi?.  297. 


British  Medical  Journal.  355 

S.  Smith,  modified,  353 

Poore.  218 

Macewen,  219 


ILLUSTRATIONS. 


XIX 


Macewen. 

219 

Hacewen. 

219 

C.,  II.  cC-  Co.,  Ford. 

441 

C,  H.  &  Co.,  Ford. 

454 

C,  H.  &  Co.,  Ford. 

137 

C,  H.  <L-  Co.,  Ford. 

137 

C,  II.  &  Co.,  Ford. 

137 

C,  II.  <£■  Co.,  Ford. 

420 

Gross. 

319 

Agnew. 

319 

S.  Smith,  modified. 

318 

493. 

S.  Smith,  modified. 

318 

Agnew. 

317 

S.  Smith,  modified. 

318 

Figs. 

597,  598,  599. 

Stimson.    S89 

,  3fJ0 

Packard. 

397 

Packard. 

395 

Fig.  5 

C,  II.  &  Co.,  Ford. 

383 

Fig. 

587. 

6'.,  II.  &  Co.,  Ford. 

384 

Fig. 

5S8.                     Gross. 

384 

Figs 

.  589,  590.       Stimson. 

385 

Fig. 

591.                    Gross. 

385 

Figs 

.  592,  593.       Stimson. 

386 

Genu  valgum,  Macewen's  method.     Figs.  298-300. 
Genu  valgum,  Ogsteu's  method.     Figs.  301,  302. 
Gorget,  blunt.     Fig.  687. 
Gorget,  hooked.     Fig.  713. 
Gouge,  curved.     Fig.  205. 
Gouge,  straight.     Fig.  204. 
Gouge,  Szymanowsky's.     Fig.  206. 
Guides,  whalebone,  Gouley's.     Fig.  647. 

Hare-lip,  complicate  1.     Fig.  495. 

Hare- lip,  double.     Fig.  494. 

Hare-lip,  simple,  double-flap  method.     Figs.  490,  491. 

Hare-lip,  simple,  double-flap  method,  Giraldes'.     Figs.  492, 

Ilure-lip,  simple,  incision  for  direct  union.     Fig.  488. 

Hare-lip,  simple,  single-flap  method.     Fig.  489. 

Hernia,  femoral,  Wood's  operation  for  the  radical  cure  of. 

Hernia,  inguinal,  direct.     Fig.  611. 

Hernia,  inguinal,  oblique.     Figs.  603,  609. 

Hernia,  inguinal,  Agnew's  apparatus  for  the  radical  cure  of. 

Hernia,  inguinal,  Wood's  apparatus  for  the  radical  cure  of. 

Hernia,  inguinal,  Wood's  operation  for  the  radical  cure  of. 
Hernia,  inguinal,  Wood's  operation  for  the  radical  cure  of. 
Hernia,  inguinal,  Wood's  operation  for  the  radical  cure  of. 
Hernia,  inguinal,  Wood's  operation  for  the  radical  cure  of. 
Hernia,  inguinal,  modification  of  Wood's  operation  for  the  radical  cure  of. 

Figs.  595,  596.     Stimson.     386,  387 
Hernia,  inguinal,  Wiltzcr's  apparatus  for  the  radical  cure  of.     Fig.  585. 

C.,H.  dt  Co,  Ford. 
Hernia,  sac  of  a.     Figs.  583.  Packard. 

Hernia,  sac  of  a,  and  contents.     Fig.  584.  Packard. 

Hernia,  umbilical,  instruments  for.     Fig.  600.  C,  II.  c6  Co.,  Ford. 

Hip-joint,  amputation  at,  by  long  anterior  and  short  posterior  flap,  Maenec. 

Figs.  450-453.  Esmarch.  290- 
Hip-joint,  amputation  at,  Dieffenbach's  circular  method.  Figs.  455-457.  Esmarch.  293, 
Hip-joint,  amputation  at,  elastic  ligature  for.     Fig.  454.  Esmarch. 

Hip-joint,  amputation  at,  Malgaigne's  method.     Fig.  453.  S.  Smith. 

Hip-joint,  amputation  at,  Malgaigtie's  method.     Figs.  459,  460.  Agnew.     295, 

Hip-joint,  excision  of,  Langenbeek's  longitudinal  incision.     Fig.  286.  Esmarch. 

Hip-joint,  excision  of,  Sayre's  line  of  incision.     Fig.  287.  New. 

Hip-joint,  excision  of,  sawing  off  head  of  femur.     Fig.  285.  Esmarch. 

Hip-joint,  exei.don  of,  White's  posterior  curved  incision.     Fig.  283.  Esmarch. 

Hip-joint,  external  rotator  muscle3  and  sciatic  nerve.     Fig.  2-sl.  Esmarch. 

Humerus,  attachments  to  head  of.     Fig.  254.  Esmarch. 

Humerus,  excision  of.  upper  end.     Fig.  252.  Esmarch. 

Humerus,  excision  of,  upper  end,  raising  tendon.     Fig.  253.  Esmarch. 

Humerus,  excision  of.  upper  end,  Rawing  bead  of  humerus.    Fig.  255.  Esmarch. 

Hydrocele,  rubber  bag  for  injecting.    Fig.  Tin.  C,  II.  db  Co.,  Ford. 

Hydrocele,  tapping  a.    Fig.  715.  Gross. 

Hypospadias,  Anger's  operation  for.    T\«.  731.  New. 

Hypospadias,  Duplay's  operation  for.     Fig.  732.  New. 

Hypospadias,  Gouley's  operation  for.    Fig.  7-;".  Gouley. 

Hypospadias,  Szymanowsky's  operation  for.    Fig.  788.  S.  Smith. 

Intubation  of  the  larynx,  O'Dwycr's  Instrument!  tor.     Fig.  790.      <'■■  If-  <C-  Co.,  Ford. 

Jaw,  the,  pre-  ing  forward,  during  administration  of  anaasthetios.    Fig.  lo.    Esmarch.     14 


382 
380 
380 
390 

292 
294 
292 
295 
296 
210 
211 
210 
209 
209 
186 
185 
186 
186 
457 
456 
464 
465 
464 
466 


XX 


ILLUSTRATIONS. 


Kelotomy.     Figs.  604-607. 

Kingsley's  nasal  lever.     Fig.  486. 

Knee-joint,  amputation  at,  bilateral  method.     Figs.  430,  431. 

Knee-joint,  amputation  at,  Carden's.     Fig.  437. 

Knee-joint,  amputation  at,  circular  method.     Figs.  432-434. 

Knee-joint,  amputation  at,  Gritti's.     Fig.  438. 

Knee-joint,  amputation  at,  long  anterior  and  short  posterior  flap. 

Knee-joint,  amputation  at,  Stokes'.     Fig.  438. 

Knee-joint,  disarticulation  at.     Figs.  432-436. 

Knee-joint,  disarticulation  at.     Figs.  430,  431. 

Knee-joint,  disarticulation  at.     Fig.  437. 

Knee-joint,  excision  of,  Langen beck's  incision.     Fig.  280. 

Knee-joint,  excision  of,  line  of  oection  in,  and  epiphyseal  cartilage  of.     Fig 

Knee-joint,  excision  of,  Mackenzie's  anterior  curved  incision.     Fig.  278. 
Knee-joint,  excision  of,  Mackenzie's  operation,  lines  of  division  of  hone. 


Packard. 


PAGE 

393,  395 

315 

Esmarch.     279 

Stimson,  modified.     282 

Esmarch.     280 

Stimson,  viodified.     282 

Figs.  435,  436. 

Esmarch.     281 

Stimson,  modified.     282 

Esmarch.     280,  281 

S.  Smith.     279 

Stimson,  modified.     282 

Esmarch.     205 


Knee-joint,  excision  of,  Ollier's  incision.     Fig.  2S2. 

Knee-joint,  tendons  at  inner  side  of.     Fig.  281. 

Knife,  metacarpal.     Fig.  319. 

Knife,  Langenbeck's,  for  staphylorrhaphy.     Fig.  518. 

Knives,  amputating.     Fig.  314. 

Knives,  hernial.     Figs.  601,  602. 

Knot,  granny.     Fig.  69. 

Knot,  reef.    Fig.  68. 

Knot,  reef,  first  step  in  tying.    Fig.  70. 

Knot,  reef,  second  step  in  tying.     Fig.  71. 

Knot,  reef,  third  step  in  tying.     Fig.  72. 

Knot,  surgeon's.     Fig.  67. 

Larynx  and  trachea,  surgical  anatomy  of.    Fig.  774. 

Larynx,  external  cartilages  of.     Fig.  773. 

Leg,  amputation  of,  bilateral  flaps.     Fig.  428. 

Leg,  amputation  of,  lower  third,  with  periosteal  reflection. 

Leg,  amputation  of,  long  external  flap.     Fig.  429. 

Leg,  transverse  section  of  middle  third  of.     Fig.  128. 

Leg,  transverse  section  of  upper  third  of.     Fig.  127. 

Lever,  Davy's,  applied.     Fig.  43. 

Ligature-carrier,  Allingham's.     Fig.  630. 

Ligature  of  arteries,  opening  sheath  of  vessel.     Fig.  92. 

Ligature  of  arteries,  passing  aneurism  needle.     Fig.  93. 

Ligature  of  arteries,  passing  prohe.     Fig.  94. 

Ligature  of  arteries,  primitive  incision.     Fig.  91. 

Ligature,  tying  a.     Fig.  66. 

Lithoelast,  Dolbeau's.     Fig.  691. 

Lithoelast,  Gouley's.    Fig.  681. 

Lithotome,  Brigtrs'  modified.    Fig.  710. 

Lithotome  (double),  Dupuytren's.     Fig.  699. 

Lithotome,  Hutchison's.     Fig.  700. 

Lithotome,  Smith's.     Fig.  698. 

Lithotomy  bisector,  Wood's.     Fig.  707. 

Lithotomy  bistoury,  Little's.    Fig.  703. 

Lithotomy  conductor  and  scoop.     Fig.  688. 

Lithotomy  director,  Little's.     Fig.  704. 

Lithotomy  knife,  Blizard's.     Fig.  686. 

Lithotomy  knife,  Dupuytren's.     Fig.  685. 


277. 

Stimson. 

Esmarch. 

Fig.  279. 

S.  Smith. 

Stimson. 

Esmarch 

C,  H.  &  Co.,  Ford. 

G,  H.  &  Co.,  Ford. 

C.,  H.  &  Co.,  Ford. 

C.,H.  d<  Co.,  Ford. 

Heath. 

Heath. 

Heath. 

Heath. 

Heath. 

Heath. 


203 
204 

205 
207 
206 
233 
328 
231 
392 


39 
39 


Gray.  494 

Esmarch.  493 

S.  Smith.  275 
Figs.  425-427. 

Original.     274,  275 

Esmarch.  278 

Esmarch.  SO 

Esmarch.  80 

Davy.  30 

C,  H.  &  Co.,  Ford.  407 

Gross.  58 

Esmarch.  58 

Esmarch.  58 

Packard.  57 

Heath.  37 

C,  H.  &  Co.,  Ford.  442 

C.,H.&  Co.,  Ford.  439 

C.,  H.  &  Co.,  Ford.  452 

G,  H.  &  Co.,  Ford.  447 

C.,H.&  Co.,  Ford.  447 

C,  H.  &  Co.,  Ford.  446 

C,  H.  &  Co.,  Ford.  450 

C,  H.  cfi  Co.,  Ford.  449 

C.,  H.  &  Co.,  Ford.  441 

C.,H.&  Co.,  Ford.  448 

G.,  H.  &  Co.,  Ford.  441 

G,  H.  &  Co.,  Ford.  441 


ILLUSTRATIONS. 


XXI 


PAGE 

Lithotomy,  lateral  incision  of  the  prostate  in.     Fig.  097.  Van  Buren  <£•  Keyes.  445 

Lithotomy,  medio-lateral  method,  Buchanan.     Fig.  709.  Van  Buren  &  Keyes.  451 

Lithotomy,  perineal,  external  incisions  in.     Fig.  708.  S.  Smith.  450 

Lithotomy  scoop,  Luer's.     Fig.  092.  C,  II.  &  Co.,  Ford.  442 

Lithotomy  staff.     Fig.  689.  C,  H.  c0  Co.,  lord.  441 

Lithotomy  stuff.     Fig.  684.  C,  H.  &  Co.,  Ford.  441 

Lithotomy  staff  and  bisector,  Wood's.     Fig.  706.  C,  IF  &  Co.,  lord.  449 

Lithotomy  staff.  Little's.     Fig.  701.  C,  IF  &  Co.,  Ford.  448 

Lithotomy  staff,  Markoe'a.     Fig.  702.  C,  //.  <£•  Co.,  Ford.  448 

Lithotomy  staff,  rectangular.     Fig.  703.  C,  II.  &  Co.,  Ford.  440 

Lithotrite  and  evacuating  catheter  combined,  author's.    Fig.  677.  C,  II.  <£•  Co.,  Ford.  436 

Lithotrite,  Bigclow's.     Fig.  664.  C,  II.  &  Co.,  Ford.  431 

Lithotrite,  fenestrated  blades,  Bigelow's.     Fig.  666.  C,  H.  &  Co.,  Ford.  431 

Lithotrite,  fenestrated  jaws.     Fig.  662.  C,  II.  d-  Co.,  Ford.  429 

Lithotrite,  Keyes'.     Figs.  667,  668.  C,  IF  &  Co.,  Ford.  431 

Lithotrite,  non-fencstrated  blades,  Bigelow's.     Fig.  665.  C.  II.  t&  Co.,  Ford.  431 

Lithotrite,  non-fenestrated  jaws.     Fig.  663.  C,  II.  tfc  Co.,  Ford.  429 

Lithotrite,  Thompson's.     Fig.  661.  x  C,  H.  i£-  Co.,  Ford.  429 

Lithotrity,  perineal,  Dolbcau's  method,  first  step.     Fig.  678.  Gouley.  437 

Lithotrity,  perineal,  Dolbeau's  method,  second  step.     Fig.  679.  Gouley.  438 

Lithotrity,  perineal,  Dolbeau's  method,  third  step.     Fig.  680.  Gouley.  438 

Little's  searcher.    Fig.  659.  C,  H.  d>  Co.,  Ford.  427 

Location  of  fissure  of  Rolando  and  special  areas.     Fig.  212.  Roberts.  141 

Loops,  Ricord's.     Fig.  180.  liicord.  125 


C,  IF  &  Co.,  Ford.  137 

New.  174 

New.  177 

Agnew.  177 

JYew.  171 

Agnew.  172 

New.  173 

New.  260 

Esmarch.  243 

Watson.  240 

Stimson .  241 

Watson.  213 

Esmarch.  243 

Esmarch.  243 

Esmarch.  243 

Watson.  242 

Esmarch.  243 

Esmarch.    240,  241 

270.           ilfafl.  197 

Esmarch.  256 

Figs.  380  383. 

i:..i,i<irch.     258,  259 

M'-tutarso-phalangcal  articulation,  amputation  at,  removal  of  a  single  toe.     Fig.  876. 

8.  Smith.  256 
Metatano-phalangea]  articulation,  amputation  at,  removal  of  great  toe,  lateral-flap 

method.     Kig.  877.                                                                                       Esmarch.  256 

o-phalangeal  articulation,  amputation  at,  removal  of  great  toe,  lateral-flap 

method,  completion  of  operation.    Fig.  378.                                               varbh.  257 
halangca]  articulation,  amputation  at,  square-flap  method.    Fig.  879. 

Esmarch.  257 

irao-phalangea]  articulatioD,  disarticulation  at  the.    Figs.  380-385.    Esmarch.    258,  259 

Kew.  260 

Mouth-gag,  Ma*on'».    Fig.  514.    '                                               0.,  B.  &  Co.,  Ford,  837 


Mallet,  lead.     Fig.  203. 
Maxillae,  superior,  removal  of  both.     Fig.  246. 
Maxilla,  inferior,  linear  guide  for  removal  of  half.     Fig.  247. 
Maxilla,  inferior,  severing  connections  of.     Fig.  248. 
Maxilla,  superior,  linear  guide  for  removal  of.     Fig.  243. 
Maxilla,  superior,  division  of  processes  of.     Fig.  244. 
Maxilla,  superior,  excision  of,  subperiosteal.     Fig.  245. 
Medio-tarsal  articulation,  amputations  at.     Fig.  386. 
Metacarpal  bones,  amputation  of  last  four,  by  transfixion.     Fig.  350. 
Metacarpal  bone,  amputation  through  one.     Fig.  346. 
Metacarpal  bone,  amputation  through  one.     Fig.  347. 
Metacarpal  bone,  stump  after  amputation  through  third.     Fig.  343. 
Metacarpal  bones,  amputation  of  last  four,  appearance  of  stump.     Fig.  3; 
Metacarpal  bones,  amputation  of  last  four,  line  of  dorsal  flap.     Fig.  351. 
Metacarpal  bones,  amputation  of  iast  four,  line  of  palmar  flap.     Fig.  349 
Metacarpal  bones,  amputation  through  fourth  and  fifth.     Fig.  347. 
Metacarpal  bones,  disarticulation  of  last  four.     Figs.  349-352. 
Metacarpophalangeal  articulation,  disarticulation  at.     Figs.  339-345. 
-o-phalangeal  articulation,  excision  of,  U-shaped  incision.     Fi. 
Mctatarso-phalangeal  articulation,  amputation  at.     Fig.  375. 
Metatarsophalangeal  articulation,  amputation  of  all  the  toes. 


XX11 


ILLUSTRATIONS. 


PAGE 

Narcs,  posterior,  plugging  the.    Fig.  756.                                            C,  H.  &  Co.,  Ford.  484 

Nasal  plugs,  ivory.     Fig.  772.                                                                  C,  H.  &  Co.,  Ford.  492 

Nerve,  circumflex.     Fig.  257.                                                                                           Gray.  188 

Nerve,  crural,  anterior,  exposed.     Fig.  216.                                                                Agneiv.  149 
Nerve,  maxillary,  superior,  Pancoast's  lines  of  incision  for  exposing.     Fig.  213. 

Pancoast,  modified.  143 

Nerve,  musculo-spiral.     Fig.  257.                                                                                    Gray.  188 

Nerve,  sciatic,  great,  exposed.     Fig.  215.                                             <                        Agnew.  148 

Nerve,  sciatic,  great,  linear  guide  to.     Fig.  123.                                                             New.  78 

Nerve,  spinal  accessory,  De  Morgan's  operation.     Fig.  214.                                   Agnew.  146 


CEsophagotomy,  internal,  Sands'  instrument  for. 
Os  calcis,  excision  of.     Fig.  271. 
Osteotomes,     iig.  292. 
Osteotrite,  Marshall's.     Fig.  226. 


Fig.  548.              C,  H.  &  Co.,  Ford.  346 

Gross.  198 

C,  H,  &  Co.,  Ford.  215 

C,  //.  it  Co.,  Ford.  163 


Palate,  cleft,  degrees  of  deformity.     Figs.  528,  529. 

Palate,  cleft,  freshening  borders  in.     Fig.  530. 

Palate,  soft,  muscles  of  the.     Fig.  532. 

Paracentesis  abdominis,  introducing  trocar.     Fig.  582. 

Paraphymosis.     Fig.  724. 

Paraphymosis,  reduction  of,  first  method.     Fig.  726. 

Paraphymosis,  reduction  of,  second  method.     Fig.  727. 

Paraphymosis,  reduction  of,  third  method.     Fig.  728. 

Paraphymosis,  results  of  the  constriction.     Fig.  725. 

Patella,  wiring  the,  fragments  united.     Fig.  793. 

Patella,  wiring  the,  wire  introduced.     Fig.  792. 

Periosteotome,  Goodwillie's.     Fig.  522. 

Periosteotome,  Sands'.     Fig.  237. 

Periosteotome,  Sayre's.     Figs.  232,  521. 

Phalangeal  articulations  of  the  hand,  disarticulation  at. 

Phalangeal  articulations  of  foot,  disarticulation  at.     Fig.  375. 

Phalangeal  articulations  of  foot,  disarticulation  at.     Fig.  376. 

Phalangeal  articulations  of  foot,  disarticulation  at.     Figs.  377-379 

Phalanges  of  hand,  attachment  of  tendons.     Fig.  332. 

Phalanx  of  hand,  amputation  of,  making  flap.     Fig.  334. 

Phalanx  of  hand,  amputation  of,  flap  completed.     Fig.  335. 

Phalanx  of  hand,  amputation  of,  by  transfixion.     Fig.  336. 

Phalanx  of  hand,  amputation  of,  opening  joint.     Fig.  337. 

Phalanx  of  hand,  flexed.     Fig.  333. 

Phymosis,  clamping  foreskin.     Fig.  720. 

Phymosis,  dorsal  slit.     Fig.  723. 

Phymosis,  Keyes'  operation  for.     Fig.  722. 

Phymosis,  steps  of  operation.     Fig.  721. 

Pin-carrier,  Post's.     JHg.  85. 

Pincers,  intestinal,  Abbe's.     Fig.  567. 

Pins,  adjustable  pointed.     Fig.  86.  ' 

Pins,  hare-lip.     Fig.  81. 

Pins.  Wood's  rectangular.     Fig.  594. 

Plastic  surgery,  jumping  method.     Fig.  474. 

Plastic  surgery,  paper  protective.     Fig.  469. 

Plastic  surgery  parallel  incisions.     Figs.  470,  471. 

Plastic  surgery,  transverse  incisions.     Figs.  472,  473. 

Polypus,  nasal,  removing  by  snare.     Fig.  764. 

Polypus,  nasal,  removing,  double  canula  in  position.    Fig.  765. 

Polypus,  nasal,  removing,  lines  of  incision.    Fig.  766. 

Polypus,  nasal,  removing,  Nelaton's  operation.     Fig.  768. 

Polypi,  naso-pharyngeal,  removing,  Langenbcck's  incisions.     Fig 


S.  Smith. 

Packard. 

Gray. 

S-  Smith,  modified. 

S.  Smith. 

S.  Smith. 

S.  Smith. 

8.  Smith. 

S.  Smith. 

British  Medical  Journal. 

British  Medical  Journal. 

C  H.  &  Co.,  Ford. 

C,  H.  &  Co.,  Ford. 

C,  H.  &  Co.,  Ford.    164, 

Figs.  333-338.    Fsmarch.     238, 

Fsmarch. 

S.  Smith. 

Fsmarch.     256, 

Original. 

Fsmarch. 

Fsmarch. 

Fsmarch. 

Fsmarch. 

Fsmarch. 

S.  Smith. 


Keyes. 

Original. 

C  H.  cfi  Co.,  Ford. 

C.,  H.  &  Co.,  Ford. 

C.,H.&  Co.,  Ford. 

C,  H.  &  Co.,  Ford. 

Stimson. 

Prince. 

Prince. 

Prince. 

Prince. 

Packard. 

Gross. 

Few. 

Few. 

767. .  New. 


330 
330 
331 
379 
461 
461 
461 
462 
461 
510 
510 
329 
167 
329 
239 
256 
256 
257 
237 
238 
238 
238 
238 
238 
459 
400 
460 
459 
46 
358 
46 
46 
386 
306 
305 
305 
306 
486 
487 
487 
488 


ILLUSTRATIONS. 


XX1I1 


Probang,  bristle.     Fig.  549. 

Probang.  bucket.     Fig.  550. 

Probang,  sponge.     Fig.  550. 

Prolapsus  ani.     Fig.  631. 

Prolapsus  ani,  complete,  with  peritoneum.     Fig.  (533. 

Prolapsus  ani,  with  invagination.     Fig.  632. 

Pylorus,  resection  of,  outlines  of  incisions  tor.    Fig.  568. 

Rectum  ending  in  a  blind  pouch.     Fig.  635. 

Rectum,  imperforate.     Fig.  034. 

Relations  of  fissures  and  convolutions  of  brain  to  external 

Respiration,  artificial,  first  movement.     Fig.  11. 
Respiration,  artificial,  second  movement.     Fig.  12. 
Retractor,  in  amputations  for  one  bone.     Fig.  329. 
Retractor,  in  amputations  for  two  bones.     Fig.  328. 
Retractor,  in  amputations,  three-tailed,  applied.     Fig.  330. 
Retractor,  in  amputation,  two-tailed,  applied.     Fig.  331. 
Retractor,  in  tracheotomy.     Fig.  776. 
Retractor,  cheek.     Fig.  515. 
Retractor,  Mott's.     Fig.  95. 
Retractor,  Parker's.     Fig.  96. 
Retractors.     Figs.  235,  236. 

Rhinoplasty,  closure  by  transverse  incision.     Fig  47o. 
Rhinoplasty,  Diefienbach's  method.     Fig.  481. 
Rhinoplasty,  Indian  method.     Fig.  483. 
Rhinoplasty,  Italian  method.     Fig.  484. 
Rhinoplasty,  Ollier's  method.    Fig.  485. 
Rhinoplasty,  repair  by  jumping.     Figs.  478,  47;). 
Rhinoplasty,  repair  by  sliding.     Figs.  476,  477. 
Rhinoplasty,  Yerneuirs  method.     Fig.  482. 
Rongeur.     Fig.  201. 

Saphenous  opening.     Fig.  613. 
Saw,  Adams'.     Fig.  289. 
Saw,  bow,  Butcher's.     Fig.  323. 
Saw,  bow,  common.     Fig.  322. 
Saw,  broad-bladed.     Fig.  320. 
Saw,  chain.     Fig.  239. 
Saw,  chain-carrier.     Fig.  240. 
Saw.  Langenbeck's.     Fig.  288. 
Saw,  Lanirenbeek's  key-hole.     Fig.  231. 
Saw,  Lente's.    Fig.  230. 
Saw,  lifting-back,  metacarpal.     Fig.  241. 
Saw,  oral,  Goodwillie's.     Fig.  526. 
Fig.  290. 
■'. rady's,  modified.      Fig.  291. 
Saw,  Szymanowski's.     Fig.  212. 
Scalpel,  method  of  holding,  first  position.    Fi^.  16. 
Scalpel,  method  of  holding,  first  position.    Fig.  17. 
Scalpel,  method  of  holding,  second  po  ition.     Figs.  18,  19. 
Scalpel,  method  of  holding,  third  position.     Figs.  '20,  21. 

Fig.  775. 
Scalpels.     Fi'_'-.  238,  284 

i  bistouries.     Fig.  15. 
Scapula,  excision  of  body.     Y'vi.  260. 
■  la,  excision  of  entire.     Fig,  249. 

of  glenoid  angle.     Fig.  206. 


PAGE 

c. 

,  H.  &  Co.,  Ford. 

347 

a 

,  11.  &  Co.,  Ford. 

347 

c. 

,  If.  J;  Co.,  Ford. 

347 

Van  Bur  en. 

410 

Van  Buren. 

411 

Van  Buren. 

410 

Billroth. 

359 

Van  Bu  re  a. 

415 

Gross. 

414 

surface  of  i 

skull. 

Fig.  211.     Roberts, 

140 

Esmarch. 

15 

Esmarch. 

16 

Esmarch. 

236 

Esmarch. 

2:;6 

Esmarch. 

236 

Esmarch. 

237 

a, 

,  11.  ct  Co.,  Ford. 

495 

c, 

H.  <£•  Co.,  Ford. 

328 

a, 

II.  &  Co.,  Ford. 

59 

c, 

11.  t0  Co.,  Ford. 

59 

C,  H.  <£•  Co.,  Ford.     164 

,  107 

New. 

308 

Dieffenbach. 

310 

New. 

312 

Stimson. 

312 

New. 

313 

Buck. 

309 

New. 

30S 

New. 

311 

a, 

11.  &  Co.,  Ford. 

136 

Gray. 

399 

c, 

11.  cfi  Co.,  Ford. 

213 

a, 

11.  &  Co.,  Ford. 

233 

a, 

11.  &  Co.,  Ford. 

233 

c, 

II.  tC-  Co.,  Ford. 

233 

c, 

II.  <(•  Co.,  Ford. 

103 

a, 

,  //.  <&  Co.,  Fcrd. 

168 

a, 

II.  tt  Co.,  Ford. 

212 

a, 

,  II.  &  Co.,  Ford. 

164 

a. 

11.  ,!•  Co..  Ford. 

104 

o.t 

II.  &  Co.,  Ford. 

109 

c, 

II.  (&  Co.,  lord. 

329 

a, 

II.  <Ss  Co.,  Ford. 

213 

a, 

II.  .(•  Co..  Ford. 

213 

a, 

II.  <!•  Co.,  For,/. 

169 

Bernard  and  Buette. 

18 

I'o  hard. 

19 

Bernard  and  Buette. 

19 

Bernard  and  Huette. 

19 

a, 

II.  ,i:  Co.,  Ford. 

495 

a, 

11.  db  Co..  Ford. 

K,| 

a, 

II.  ,/■  Co.,  Ford. 

IS 

Ni  >"■ 

is:; 

Kew. 

182 

Esmarch. 

lh7 

XXIV 


ILLUSTRATIONS. 


Scapula,  excision  of  subperiosteal.     Fig.  251.  New. 

Scoop  and  conductor,  lithotomy.     Fig.  688.  01,  R.  &  Co.,  lord. 

Scoop,  Hebra's.     Fig.  224.  01,  H.  6b  Co.,  Ford. 

Scoop,  Volkniann's.    Fig.  223.  01,  H.  6b  Co.,  Ford. 

Scissors,  Allingham's.     Fig.  629.  C,  H.  6b  Co.,  Ford. 

Scissors,  curved.    Fig.  25.  01,  H.  6b  Co.,  Ford. 

Scissors,  curved  for  staphylorrhaphy,  etc.     Fig.  520.  C,  H.  6b  Co.,  Ford. 

Scissors,  pbymosis,  Taylor's.     Fig.  719.  01,  H.  6b  Co.,  Ford. 

Scissors,  straight,  probe-pointed.     Fig.  20.  C,  H.  &  Co.,  Ford. 

Searcher,  Gouley's.     Fig.  600.  C,  H.  6b  Co.,  Ford. 

Searcher,  Little's.    Fig.  659.  O,  H.  6b  Co.,  Ford. 

Searcher,  Thompson's.     Fig.  G5S.  01,  H.  6b  Co.,  Ford. 

Serrefine,  Langcnbeck's.     Fig.  55.  O.,  H.  6b  Co.,  Ford. 

Serrefine,  wire.     Fig.  56.  O.,  H.  6b  Co.,  Ford. 

Shoulder-joint,  amputation  at,  by  circular  incision,  flaps  united.  Fig.  371.      Fsmarch. 
Shoulder-joint,  amputation  at,  by  circular  incision,  removal  of  bone.     Fig.  370. 

Esmarch. 


Shoulder-joint,  amputation  at,  oval,  Larrey.     Fig.  372. 

Shoulder-joint,  amputation  at,  oval,  Larrey,  forming  inner  flap. 

Shoulder-joint,  amputation  at,  Spence's  method.     Fig.  374. 

Shoulder- joint,  disarticulation  of,  Dupuytren.    Fig.  367. 

Shoulder-joint,  disarticulation  of,  Dupuytren,  flaps  united.     Fig.  369. 

Shoulder-joint,  disarticulation  of,  Dupuytren,  making  inner  flap.     Fi 

Skull,  course  of  arteries  and  sinuses  of.     Fig.  209. 

Snare,  polypus,  nasal,  Codman  and  Shurtleff's.     Fig.  762, 

Snare,  polypus,  nasal,  Jarvis'.     Fig.  763. 

Snare,  polypus,  nasal,  Sexton's.     Fig.  761. 

Sonde  a  dart.     Fig.  712. 

Sound,  tunneled,  Gouley's.     Fig.  648. 

Speculum,  rectal,  Allingham's.     Fig.  G18. 

Speculum,  rectal,  bivalve.     Fig.  616. 

Speculum,  rectal,  Williams'.     Fig.  617. 

Speculum,  rectal,  Thebaud's  dilating.     Fig.  625. 


Fig.  373. 


368. 


S.  Smith. 

S.  Smith. 

Fsmarch. 

Fsmarch. 

Esmarch. 

Fsmarch. 

Esmarch. 
C,  II.  6b  Co.,  Ford. 
01,  H.  6b  Co.,  Ford. 
C,  II.  &  Co.,  Ford. 
C,  H.  6b  Co.,  Ford. 
C,  H.  6b  Co.,  Ford. 
C,  II.  &  Co.,  Ford. 
C,  H.  &  Co.,  Ford. 
C,  H.  6b  Co.,  Ford. 
C,  H.  6b  Co.,  Ford. 


Spine,  curvature  of  the,  Sayre's  apparatus  for.    Figs.  462-464.  O.,  H.  6b  Co.,  Ford.     29S. 

Staphylorrhaphy,  freshening  borders.     Fig.  531.  Packard. 

Staphylorrhaphy,  looped  suture  in.     Fig.  534.  S.  Smith. 

Stomatoplasty.     Fig.  512.  Buck. 

Suspensory,  Morgan's.     Fig.  172.  Gross. 

Suture,  continuous,  or  Glover's.     Figs.  80,  555.  Esmarch.     44. 

Suture,  hare-lip.     Figs.  82,  83.  Esmarch. 

Suture,  interrupted.     Fig.  7S.  Esmarch. 

Suture,  intestinal,  Czerny-Lembert's.     Fig.  561.  Mosetig-Moorhof. 

Suture,  intestinal,  Gely's,  external  appearance.     Fig.  557.  Stimson. 

Suture,  intestinal,  Gely's,  internal  appearance.     Fig.  558.                                          Otis. 

Suture,  intestinal,  Gussenbauer's.     Fig.  562.  MtsJig-Moorlwf. 

Suture,  intestinal,  Jobert's.     Figs.  559,  500.  Esmarch. 

Suture,  intestinal,  Lembert's.     Figs.  554-556.  Esmarch. 

Suture,  quilled.     Fig.  81.  Thomas  Bryant. 

Sutures,  tension  of.     Fig.  79.  Thomas  Bryant. 

Syringe,  debris,  Van  Buren's.    Fig.  693.  C,  II.  6b  Co.,  Ford. 


PAGE 

184 
441 
162 
162 
407 

21 
329 
459 

21 
427 
427 
427 

34 

34 
254 

253 
254 
254 
254 
251 
252 
252 
138 
486 
486 
486 
454 
421 
402 
402 
402 
406 
299 
330 
333 
327 
121 
349 
45 
44 
351 
350 
350 
351 
351 
349 
44 
44 
443 


01,  H.  &  Co.,  Ford.    491 

New.     200 
260 


Tampon,  trachea,  Trendelenburg's.     Fig.  769. 

Tarso  metatarsal  articulation,  amputations  at.     Fig.  386. 

Tarso-metatarsal  articulation,  amputation  at,  Lisfranc's.     Fig.  386.  JSew. 

Tarso-metatarsal  articulation,  amputation  at,  Bauden's  modification  of  Lisfranc's. 

Fig.  3S6.         New.     260 
Tarso-metatarsal  articulation,  amputation  at,  Hey's  modification  of  Lisfranc's. 

Fig.  386.        New.     260 


ILLUSTRATIONS. 


XXV 


Tarso-inetatarsal  articulation,  amputation  at,  Skey's  modification  of  Lisfranc's. 

Fig.  386.        jS'ew.     260 
Tarso-metutarsal  articulation,  disarticulation  at.     Figs.  387-391.  Esmarch.     261,  202 

Tarso -metatarsal  articulation,  disarticulation  at.     Figs.  411,  412.  Gross.    270 

T.irso-metatarsal  articulation,  disarticulation  at.     Fig.  410.  Original.     269 

Tarso-metatarsal  articulation,  disarticulation  at.     Fig.  416.  S.  Smith.     271 

Tenaculum.     Figs.  59,  519.  ft,  H.  d-  Co.,  Ford.     35,  328 

Tenaculum,  application  of,  to  vessels.     Fig.  60.  Packard.       35 

Tenaculum-retractor.     Fig.  777.  ft,  //.  d>  Co.,  Ford.     495 

Tendon,  dividing  a.     Fig.  220.  Sayre.     152 

Tendons,  flexor,  of  lingers,  linear  guide  to.     Fig.  161.  Gross.     106 

Tenotomes.     Figs.  217,  218.  C,  E.  d-  Co.,  Ford.     151,  152 

Thigh,  amputation  of,  bilateral  flaps.     Fig.  428.  8.  Smith.     275 

Thigh,  amputation  of,  Celsus'  single  circular  incision.     Figs.  442,  443.  Esmarch. 

Thigh,  amputation  of,  circular-integumentary  flap,  amputated  portion. 

Fig.  441.  Gross. 

Thigh,  amputation  of,  circular-integumentary  flap,  conical  cavity  of  stump. 

Fig.  440.     Gross,  modified. 
Thigh,  amputation  of,  periosteal  flap.     Fig.  439.  Esmarch,  moJijied. 

Toe,  amputation  at  the  metatarso-phalangeal  articulation.     Fig.  375.  Esmarch. 

Toes,  amputation  of  all,  at  the  metatarso- phalangeal  articulation.     Figs.  0S0-383. 

Esmarch.     25S,  259 
Toe,  amputation  of  a  single,  at  the  metatarso-phalangeal  articulation.     Fig.  376. 

<S'.  Smith. 
Toe,  amputation  of  a  single,  at  the  metatarso-phalangeal  articulation,  lateral-flap 

method,     iig.  377.     Esmarch. 
Toe,  amputation  of  a  single,  at  the  metatarso-phalangeal  articulation,  lateral -flap 

method,  completion  of  operation.     Fig.  378.     Esmarch. 
Toe,  amputation  of  a  single,  at  the  metatarso-phalangeal  articulation,  square- 
flap  method.     Fig.  379.     Esmarch. 
Toe,  great,  amputation  of,  at  proximal  end  of  metatarsal  bone.    Fig.  384.        Esmarch. 
Toe,  little,  amputation  of,  and  metatarsal  bone.     Fig.  385.  Esmarch. 

Toe-nail,  ingrowing.     Fig.  467.  Gross. 

Tongue,  excision  of,  6craseur  in  position.     Fig.  544.  Agnew. 

Tongue,  excision  of,  Kocher's  operation.     Fig.  546.  Kocher. 

Tongue,  excision  of,  Regnoh's  incision.     Fig.  545.  Gross. 

Tongue,  excision  of,  removal  of  a  V-sbaped  piece.     Fior.  541.  S.  Smith. 

Tongue,  excision  of,  removal  of  a  V-shaped  piece,  flaps  united.     Fig.  542.      £.  Smith. 
Tongue,  hypertrophy  of.     Fig.  543.  Buck. 

Tongue,  the.  drawing  forward,  during  administration  of  anaesthetics.    Fig.  9.    Esmarch. 
Tonsill.it'. me.  Hamilton's.     Fig.  539. 
Tonsillotome,  Mackenzie's.     Fig.  540 
Tonsillotome,  Tiemann's.     Fig.  538. 
Tourniquet,  abdominal,  Brandis'.     Fig.  449 


Tourniquet,  abdominal,  compression  pad  and  elastic  band. 
Tourniquet,  abdominal,  elastic  ligature.     Fie.  454. 
Tourniquet,  abdominal,  Esmareh's.     FiLr.  445. 
Tourniquet,  abdominal,  Esmareh's.  applied.     Fig.  446. 
Tourniquet,  abdominal,  Lister's.     Fig.  447. 
Tourniquet,  abdominal,  Poncoast's,    Fig.  444. 
Tourniquet,  Knebcl's  improved.     Fig.  42. 
Tourniquet,  Petit' §.     Fi 

niquet,  Pctit's,  applied  to  femoral  artery.     Fig.  40. 
Trachea  and  larynx,  surgical  anatomy  of.    Fig.  774. 
Trachea,  opening  the.     Fig.  787. 
Trachea,  vascular  relations  of  the.    Fig.  789. 
Transfusion  apparatus,  Hull's.     Fig.  187. 
Transfusion  apparatus,  Collins'.    Fig.  185. 


ft,  //.  <C-  Co.,  Ford. 

C,  II.  ct  Co.,  Ford. 

ft,  //.  &  Co..  Ford. 

Esmarch. 


Fig.  448 


Esmarch. 

Esmarch. 
ft,  //.  &  Co.,  Ford. 
ft,  IT.  <(•  Co.,  Ford. 
ft,  //.  eft  Co.,  Ford. 
ft,  II.  eft  Co..  Ford. 

Monarch. 

Esmarch. 

Esmarch. 
Gray. 

/  march. 

I'ickard. 
C,  II.  tfi  Co.,  Ford. 

Esmarch. 


286 

285 

2S4 
284 
256 


256 


256 


■M 


257 
259 
259 
302 
341 
343 
342 
339 
339 
340 
13 
337 
338 
337 
289 
288 
292 
287 
288 
28S 
287 
29 
28 
29 
494 
498 
499 
130 
129 


XXVI 


ILLUSTRATIONS. 


Transfusion  apparatus,  Fryer's.     Fig. '184. 

Transfusion,  direct.     Fig.  183. 

Transfusion,  introducing  tube.     Fig.  182. 

Transfusion,  removing  fibrin  from  blood.     Fig.  186. 

Transfusion,  straining  blood.     Fig.  188. 

Trendelenburg's  rod.     Fig.  44. 

Trephine,  crown.     Fig.  195,  196. 

Trephine,  crown,  application  of.     Fig.  210. 

Trephine,  Gait's.     Fig.  197. 

Trocar  and  canula.     Fig.  579. 

Trocar,  rectum.     Fig.  655. 

Trocar,  rectum,  Buck's.     Fig.  656. 

Trocar,  Wood-Harris.     Fig.  578. 

Tube  (curved)  and  guide,  Keyes'.     Fig.  676. 

Tube  (straight)  and  guide,  Keyes'.     Fig.  675. 

Tube,  trachea,  bivalve.     Figs.  783,  784. 

Tube,  trachea,  hard  rubber.     Fig.  782. 

Tube,  trachea,  in  position.     Fig.  788. 

Tube,  trachea,  silver.     Fig.  781. 

Uranoplasty.     Fig.  535. 

Urethra,  tapping  the.     Fig.  752. 

Urethrometcr,  Otis'.     Fig.  748. 

Urethroplasty.     Fig.  738. 

Urethroplasty,  Nelaton's  operation.     Fig.  739. 

Urethroplasty,  Kigaud's  operation.     Fig.  740. 

Urethrotome,  Otis'.     Figs.  749,  750. 

Urethrotome,  Feet's.     Fig.  751. 

Urethrotomy,  operation  of,  drawing  apart  lips  of  the  incision. 

Urethrotomy  staff,  grooved,  Syme's.     Fig.  743. 

Variocele,  Keyes'  needle  for.     Fig.  179. 
Varicocele,  treatment  by  elastic  traction.     Fig.  178. 
Varicocele,  treatment  by  occlusion  by  pins.     Fig.  174. 
Varicocele,  treatment  by  Eicord's  loops.     Fig.  lbO. 
Varicocele,  Videl's  operation.     Figs.  175-177. 
Veins,  spermatic,  varicose.     Fig.  171. 
Venesection  with  scalpel.     Fig.  181. 

Webbed  fingers.     Fig.  465. 

Webbed  fincrcrs,  Nelaton's  operation.     Fig.  466. 

Whitehead's  forceps.     Figs.  516,  517. 

Whitehead's  hoe.     Fig.  527. 

Whitehead's  mouth-gag.     Fi?.  513. 

Whitehead's  spiral  needle.     Fig.  523. 

Wrist-joint,  amputation  at,  circular  method.     Fig.  353. 

Wrist-joint,  amputation  at,  flaps  united.     Fig.  354. 

Wrist-joint,  amputation  at,  double  flap.     Figs.  355,  356,  358. 

Wrist-joint,  amputation  at,  single  palmar  flap.     Fig.  357. 

Wrist-joint,  amputation  at,  double  flap,  appearance  of  stump. 

Wrist-joint,  excision  of,  Langenbeck's  incisions.     Fig.  268. 

Wrist-joint,  excision  of,  lateral  incisions.     Fi?.  264. 

Wrist-joint,  excision  of,  Lifter's  incisions.     Fig.  269. 


PAGE 

a, 

H.  <£■  Co.,  Ford. 

128 

€.., 

,  H.  &  Co.,  Ford. 

128 

Esmarch. 

127 

' 

Esmarch. 

129 

Esmarch. 

131 

C, 

II.  tfi  Co.,  Ford. 

31 

a, 

II.  £  Co.,  Ford. 

136 

Esmarch. 

138 

c. 

,  E.  &  Co.,  Ford. 

136 

c. 

,  E~.  db  Co.,  Ford. 

378 

a., 

E.  &  Co.,  Ford. 

425 

a. 

,  E.  &  Co.,  Ford. 

425 

a 

,  E.  &  Co.,  Ford. 

S78 

c. 

,  E.  &  Co.,  Ford. 

434 

c. 

,  E.  &  Co.,  Fori. 

434 

a. 

,  E.  &  Co.,  Ford. 

496 

a. 

,  E.  &  Co.,  Ford. 

496 

Esmarch,  modified. 

498 

c. 

,  II.  &  Co.,  Ford. 

496 

Gross. 

334 

Bumslead  &  Taylor. 

478 

a, 

,  II.  dt  Co.,  Ford. 

476 

Stimson. 

470 

Original. 

470 

Original. 

471 

C,  II.  , 

&  Co.,  Ford.    476 

,477 

C, 

E.  tt-  Co.,  Ford. 

477 

Fig.  744.           Original. 

473 

a, 

II.  &  Co.,  Ford. 

472 

c, 

,  II.  &  Co.,  Ford. 

124 

Gross. 

124 

Packard. 

123 

Eicord. 

125 

Packard. 

123 

Gross. 

121 

Esmarch. 

125 

Annandale. 

300 

Annandale. 

301 

a, 

E.  &  Co.,  Ford. 

328 

a, 

E.  &  Co.,  Ford. 

330 

a, 

E.  &  Co.,  Ford. 

327 

a, 

E.  &  Co.,  Ford. 

329 

Esmarch. 

244 

Esmarch. 

244 

Esmarch.     245, 

.  246 

S.  Smith. 

245 

Fig.  3 

59.        Esmarch. 

246 

Esmarch. 

195 

Esmarch. 

193 

IStimson. 

196 

OPERATIVE   SURGERY. 


CHAPTER  I. 

GENERAL   CONSIDERATIONS. 

Operative  Surgery  treats  of  the  manual  procedures  necessary  to 
properly  accomplish  the  surgical  object  in  view.  The  operation  to  be 
done  is  the  execution  of  a  verdict  that  is,  or  should  be,  based  upon 
surgical  principles  and  laws  in  a  sense  comparable  to  legal  proceedings 
in  the  Courts  of  Justice.  The  surgeon,  in  most  instances,  however, 
holds  the  threefold  position  of  judge,  jury,  and  executioner.  It  is, 
therefore,  very  essential  for  the  welfare  of  the  patient  that  he  properly 
interpret  the  surgical  laws  and  principles  relating  to  the  case,  in  order 
that  the  verdict  to  follow  may  be  just,  and  its  execution  cast  no  oppro- 
brium upon  himself  or  his  profession.  To  be  able  to  operate  under- 
standing^, requires  not  only  a  thorough  knowledge  of  the  principles 
of  surgery,  but  a  fair  knowledge  of  the  ways  and  means  of  accomplish- 
ing the  desired  purpose. 

It  is  not  enough  to  be  able  to  remove  in  a  skillful  manner  an  offend- 
ing member  or  disease,  but  it  is  equally  important  for  the  surgeon  to 
so  prepare  the  patient  and  himself  that  no  unanticipated  complication 
can  occur  immediately  prior  to,  during,  or  subsequent  to  the  opera- 
tion. 

Regarding  the  principles  of  surgery  proper,  the  reader  is  referred 
to  the  many  works  upon  that  subject ;  since  it  is  not  the  intention  of 
the  author  to  intrude  upon  this  department  of  surgery,  except  in  so 
far  as  it  may  be  found  expedient  to  apply  them  to  the  immediate  safety 
of  the  patient  during  and  subsequent  to  the  operation. 

Prior  to  an  operation,  especially  if  it  be  one  of  any  magnitude,  it 
is  essential  that  the  following  facts  be  ascertained  : 

First.  The  physical  condition  of  the  heart,  lungs,  kidneys,  brain, 
and  great  vessels. 

Second.  If  there  be  an  acute  surgical  or  other  complication  of  the 
iti;d  organs  of  the  body,  joints,  serous  cavities,  etc. 

Third.   If  the  patient  be  suffering  from  shock. 
1 


2  OPERATIVE   SURGERY. 

Fourth.  If  the  patient  be  anaemic  or  scorbutic.  If  he  have  syphi- 
lis, phthisis,  epilepsy,  diabetes,  or  be  in  danger  of  delirium  tremens. 

Fifth.  If  he  be  willing  and  ready  for  the  operation. 

Upon  the  healthful  condition  of  the  heart,  lungs,  brain,  etc.,  may 
depend  the  expediency  of  giving  an  anaesthetic,  and  the  choice  be- 
tween them.  If  the  kidneys  be  diseased,  it  may  be  inadvisable  to 
operate  upon  the  urethra  or  bladder,  or  even  to  give  an  anaesthetic ;  if 
the  great  vessels  be  dilated  or  atheromatous,  much  discretion  must  be 
employed  in  its  selection  and  administration.  It  should  not  be  for- 
gotten, however,  that  the  mental  emotion  and  physical  suffering  at- 
tendant upon  an  operation,  when  performed  without  anaesthesia,  may 
be  of  greater  moment  than  with  its  use. 

If  the  injury  demanding  an  operation  be  recent,  and  the  patient 
be  suffering  from  a  severe  shock,  it  should  be  deferred  until  reaction 
is  established.  If  the  shock  be  out  of  proportion  to  the  visible  injury, 
a  careful  examination  of  the  patient  must  be  made  to  ascertain  its 
cause.  If  a  complicating  injury  be  discovered,  which  of  itself  im- 
perils the  life  of  the  patient,  all  idea  of  an  immediate  operation  must 
be  deferred.  These  thoughtful  attentions  will  lessen  the  pungency  of 
the  oft-repeated  satirical  expression,  "  The  operation  was  successful, 
but  the  patient  succumbed." 

If  the  patient  be  already  anaemic,  or  scorbutic,  the  loss  of  blood 
added  to  the  shock  of  the  operation  may  expose  him  to  greater  dangers 
than  if  the  operation  be  postponed.  Unfortunately,  however,  in  a 
majority  of  cases,  the  conditions  calling  for  operative  interference  are 
the  prime  factors  which  determine  the  degree  of  the  blood  changes, 
and  will  not,  of  themselves,  admit  of  any  delay. 

The  existence  of  syphilis,  phthisis,  diabetes,  etc.,  exerts  a  marked 
influence  on  the  recovery,  and  their  importance  must  not  be  under- 
estimated in  connection  with  this  fact.  If  a  patient  be  addicted  to 
the  continuous  use  of  intoxicating  beverages,  and  worse  still,  if  he 
receive  an  injury  during  a  prolonged  debauch,  it  seriously  complicates 
his  case,  not  only  directly  from  the  previous  effects  upon  his  bodily 
vigor,  but  from  the  impending  danger  of  delirium  tremens. 

It  is  not  necessary  to  the  successful  issue  of  an  operation  that  the 
patient  be  ready  and  willing  ;  yet,  if  such  a  fortunate  combination  be 
present,  it  will  weigh  heavily  in  favor  of  ultimate  success.  It  is 
prudent,  however,  that  he  should  be  ready  in  a  legal  sense ;  that  is, 
that  his  consent  be  gained. 

If  the  operation  be  a  dernier  ressort  he  should  be  given  the  oppor- 
tunity of  adjusting  his  business  and  spiritual  affairs.  If  they  be  pre- 
maturely adjusted — if  such  be  possible — the  knowledge  of  it,  and  the 
quiet  of  mind  resulting  therefrom,  will  become  valuable  aids  toward 
his  recovery. 

Season  of  the  Year. — Autumn  and  spring  are  the  best  seasons  for 


GENERAL  CONSIDERATIONS.  3 

surgical  operations.  Still,  it  is  not  always  practicable  to  render  this 
knowledge  available.  It  is  best  to  avoid,  as  far  as  possible,  extremes 
of  temperature.  Fair  weather  with  an  ascending  barometer  is  more 
propitious  than  the  reverse. 

The  time  of  day  should  be  such  as  to  secure  a  good  light  until  the 
completion  of  the  operation. 

Tlie  surroundings  of  the  patient  subsequent  to  the  operation  are 
to  be  studied  with  great  care.  The  sick-room  should  be  commodious 
and  sunny,  and,  when  possible,  be  on  the  second  floor,  with  a  southern 
exposure,  and  with  the  door  and  windows  so  arranged  that  it  can 
be  easily  ventilated  without  exposure  to  improper  air-currents.  All 
sewer-connected  wash-basins  or  other  receptacles  of  waste  must  be 
excluded  from  the  room.  The  plainer  the  walls  and  ceilings  the 
better ;  for,  if  the  patient  become  delirious,  the  outlines  and  figures 
of  modern  decorations  may  invite  and  form  the  basis  of  exciting 
illusions.  It  is  better  at  all  times,  for  hygienic  reasons,  that  the 
room  be  as  plain  as  possible,  and  that  all  unnecessary  articles  be  re- 
moved therefrom,  especially  when  it  is  to  be  reoccupied  as  a  sick- 
room. During  convalescence,  and  after  all  dangers  from  septic  in- 
fluences are  passed,  objects  of  interest  may  be  placed  upon  the  man- 
tels and  walls,  which  can  be  varied  from  time  to  time  to  please  the 
fancies  of  the  patient. 

The  temperature  of  the  room  should  be  maintained  at  about  70° 
Fahr.  Pure  air  is  quite  as  essential  to  a  rapid  recovery  as  good  food. 
The  room  should  be  thoroughly  ventilated  at  least  once  each  day  ;  this 
can  be  readily  done  by  opening  the  windows  and  doors,  thereby  creat- 
ing a  through-and-through  current,  at  the  same  time  using  caution 
that  the  patient  be  protected  from  direct  draughts,  and  be  well  cov- 
ered till  the  temperature  shall  have  resumed  a  suitable  standard.  The 
presence  of  flowers  and  other  odoriferous  agents  are  not  to  be  en- 
couraged in  the  sick-room,  although  they  may  exert  a  good  moral 
influence,  in  that  they  remind  the  patient  of  the  existence  of  sympa- 
thizing friends  without.  It  must  always  be  made  as  cheerful  as  pos- 
sible, consequently  all  annoyances  are  to  be  removed  whenever  the 
fancies  of  the  patient  indicate  their  presence. 

Place  for  an  Operation. — The  office  of  the  surgeon  is  not  a  proper 
place  to  do  operations  of  any  magnitude,  or  even  those  requiring  the 
use  of  an  anaesthetic,  because  the  rest  and  quiet  that  should  follow  the 
former  can  not  be  had  if  the  patient  be  removed  ;  and,  moreover, 
anaesthesia  is  often  followed  by  persistent  nausea  and  vomiting,  and 
not  infrequently  by  prolonged  noisy  delirium. 

Nursing. — All  who  require  the  services  of  a  nurse  should,  if  possi- 
ble, secure  one  who  has  had  considerable  experience  and  is  a  professional. 
The  well-intended  attentions  and  observations  of  solicitous  friends  are 
often  burdensome  to  the  patient,  and  misguiding  to  the  surgeon,  and  are 


4  OPERATIVE   SURGERY. 

as  apt  to  be  controlled  by  their  sympathy  for  the  patient,  as  by  the  de- 
sire to  consult  the  express  wishes  of  the  medical  attendant.  It  is  well 
to  remember,  however,  that  a  discreet  friend  is  a  far  better  attendant 
than  a  garrulous  self-sufficient  nurse.  The  attendant  who  proffers  his 
views  and  experience  in  the  sick-chamber,  hoping  thereby  to  honestly 
impress  all  present  with  his  worth,  is  as  detrimental  to  the  moral  at- 
mosphere of  the  room,  as  closed  windows  and  doors  are  to  the  physical. 

Preparatory  Treatment. — This  should  be  directed  to  the  improve- 
ment of  the  patient's  general  condition  ;  also  to  directly  combating 
the  constitutional  diseases  which  may  affect  the  ultimate  result. 

Diet. — Precisely  the  variety  and  amount  of  food  to  be  given  are 
matters  which  must  be  determined  by  the  requirements  of  the  indi- 
vidual cases.  Milk,  eggs,  milk-punch,  stimulants,  etc.,  are  stereo- 
typed articles,  the  usefulness  of  which  is  well  established.  They 
should  not,  in  any  instance,  if  it  be  possible  to  avoid  it,  be  substituted 
by  the  traditional  beef-tea,  and  more  elaborate  chemical  extracts  with 
which  the  market  is  cloyed. 

The  requirements  necessary  to  secure  favorable  results  in  surgical 
operations  may  be  divided  into  the  essential  and  the  precautionary. 

The  essential  requirements  consist  of  such  implements,  agents,  and 
information  as  are  necessary  to  the  proper  performance  of  an  oj)era- 
tion,  as  well  as  to  a  due  consideration  of  the  result. 

The  precautionary  are  those  which  are  useful  in  the  various  emer- 
gencies that  may  complicate  an  operation  ;  and  it  is  necessary,  if  they 
are  to  be  of  practical  utility,  that  they  should  be  at  hand  and  be  pre- 
pared for  immediate  use. 

ESSENTIAL  REQUIREMENTS. 

First.  A  knowledge  of  the  usual  result  of  the  operation  about  to 
be  performed. 

Second.  A  practical  knowledge  of  the  anatomy  of  the  parts  in- 
volved in  the  operation. 

Third.  Anassthetics  ;  proper  means  of  administering,  and  of  com- 
bating their  dangers. 

Fourth.  The  necessary  implements  and  a  knowledge  of  their  use. 

Fifth.  Suitable  trays  to  hold  instruments. 

Sixth.  Operating-table,  sponges,  empty  vessels,  antiseptic  solu- 
tions, and  rubber  cloths. 

Seventh.  Agents  for  controlling  hemorrhage. 

Eighth.  Assistants  of  suitable  number  and  proficiency. 

Ninth.  A  patient  properly  prepared  for  the  procedure. 

Tenth.  Proper  materials  for  dressing  wounds  and  a  knowledge  of 
their  use. 

A  knowledge  of  the  usual  result  of  the  operation  about  to  be  per- 
formed is  one  of  the  chief  factors  to  be  employed  to  determine  its 


GENERAL   CONSIDERATIONS.  5 

propriety ;  and  is,  therefore,  entitled  to  be  first  considered.  This 
knowledge  can  be  gained  from  only  two  sources  :  First,  the  personal 
experience  of  the  operator  and  of  those  from  whom  he  may  be  able  to 
obtain  an  opinion.  Second,  the  recorded  experience  of  the  profession. 
The  first  implies  the  calling  of  a  consultation,  which  should  always 
be  done  whenever  a  doubt  exists  in  the  mind  of  the  operator  ;  such  a 
course  not  only  offers  to  the  patient  every  available  chance,  but,  in  un- 
fortunate results,  frequently  serves  to  sooth  the  feelings  of  disappoint- 
ment experienced  by  all  concerned.  If  a  consultation  be  not  feasible, 
the  surgeon  must  then  rely  upon  the  recorded  practical  knowledge  of 
the  profession,  a  knowledge  which  is  modified  from  year  to  year  by  the 
improvement  and  increase  of  surgical  expedients ;  consecmently,  the 
statistics  of  a  certain  operation  must  be  recent,  if  they  are  to  be  of  the 
greatest  practical  utility. 

A  practical  understanding  of  the  anatomy  of  the  part  involved  in  an 
operation  is  always  essential  to  the  comfort  of  the  operator,  and  often 
to  the  safety  of  the  patient.  This  knowledge  is  somewhat  difficult  to 
obtain  and  is  always  of  uncertain  tenure.  In  the  case  of  the  general 
practitioner,  it  consists  chiefly  of  that  which  can  be  gleaned  from  text- 
books and  anatomical  plates  :  often  called  "  Flat  Anatomy,"  added  to 
the  anatomical  knowledge  retained  since  graduation.  Those  who  reside 
in  large  cities  can  avail  themselves  of  the  ample  opportunities  afforded, 
to  rehearse  important  operations.  When  the  dead  can  be  made  gen- 
erally subservient  to  the  welfare  of  the  living,  then  all  medical  men  can 
avail  themselves  of  the  only  means  of  becoming  fully  able  to  surgically 
"Do  unto  others  as  they  would  that  others  should  do  unto  them." 

Anaesthetics. — The  anaesthetics  in  established  use  are  ether,  chloro- 
form, and  nitrous  oxide  or  laughing-gas. 

Ether. — This  is  employed  far  more  in  surgery  than  both  the  oth- 
ers combined.  The  chief  objections  to  its  use  are  its  pungency,  the 
liability  of  its  causing  nausea  and  vomiting,  its  inflammability,  and 
production  of  cerebral  excitement. 

Its  disagreeable  pungency  can  be  lessened,  in  fact,  almost  entirely 
obviated,  by  allowing  a  good  volume  of  air  to  mingle  with  it  during 
the  first  moments  of  its  administration.  One  has  but  to  cover  his  own 
face  with  the  well-charged  ether-cone  in  common  use,  to  realize  the 
sense  of  impending  suffocation,  which  is  experienced  by  the  unwary 
patient,  whose  struggles  to  resist  it  are  often  violent,  and  suggestive  of 
the  belief  that,  upon  his  part,  the  struggle  is  for  life.  Scenes  of  this 
kind  should  always  be  avoided,  more  especially  when  the  patient  is 
suffering  from  any  complications  which  will  expose  him  to  an  addi- 
tional peril.  The  nausea  and  vomiting  following,  are  not  of  sufficient 
importance  to  contra-indicate  the  use  of  ether,  except  in  such  cases  in 
which  it  would  be  otherwise  objectionable. 

The  resultant  vomiting  is  chiefly  dangerous,  where  solid  food  has 


Q  OPERATIVE   SURGERY. 

been  recently  taken,  in  often  causing  suffocation  by  its  entering  the 
larynx  and  trachea. 

Inflammability. — This  is  only  to  be  regarded  while  operating  in 
the  presence  of  artificial  light  or  with  the  actual  cautery.  There  is, 
however,  but  little  danger,  since  the  weight  of  the  vapor  causes  it  to 
create  a  downward  current,  thereby  tending  to  remove  it  from  contact 
with  the  igniting  agent.  It  is  safer,  however,  for  all  concerned,  to 
treat  it  on  such  occasions  as  if  it  were  only  awaiting  the  slightest 
opportunity  to  assert  its  power.  The  cerebral  excitement  which  often 
precedes  complete  anaesthesia  may  be  due  to  an  idiosyncrasy,  or  be  aug- 
mented by  surrounding  circumstances.  The  patient  should  be  assured 
that  no  harm  will  attend  its  administration  ;  it  should  be  given  in  a 
gentle  manner,  slowly  in  the  beginning,  that  the  mucous  membranes 
may  not  suffer  too  great  irritation,  and  complete  quietude  on  the  part 
of  all  present  should  be  maintained,  since  talking  often  serves  to  excite 
the  inebriated  fancies,  and  forms  the  basis  of  disorderly  actions.  The 
handling  of  the  part  to  be  operated  upon,  prior  to  complete  insensi- 
bility, is  a  fertile  source  of  annoyance,  and  is  often  suggestive  to  the 
patient  of  the  impending  operation.  These  are  precautions  which 
should  be  observed  during  the  administration  of  all  anaesthetics. 


Fig.  1. — Esmarch's  chloroform  inhaler. 

Chloroform  is  more  dangerous  than  ether,  and  should  not  be  used, 
unless  the  contra-indications  to  the  use  of  ether  are  exceedingly  strong. 
Although  it  has  a  pleasant  odor  and  is  devoid  of  pungency,  is  less  liable  to 
induce  vomiting  and  cerebral  excitement,  is  non-inflammable  and  more 
rapid  in  action  than  ether,  yet  these  facts  weigh  but  little  as  against 
the  additional  dangers  incurred  by  its  use.  At  the  present  time  its 
application  as  an  anaesthetic  is  almost  entirely  limited  to  children,  and 
to  obstetrical  practice.  Chloroform  can  be  administered  by  pouring  a 
few  drops  on  a  napkin  which  is  held  a  short  distance  from  the  nose, 
or  by  the  agency  of  an  inhaler  devised  by  Esmarch  (Fig.  1),  which 


GENERAL   CONSIDERATIONS.  7 

consists  simply  of  a  properly  shaped  wire  frame-work  covered  by  flan- 
nel and  fastened  to  the  head. 

Nitrous  oxide  is  the  most  agreeable  and  least  dangerous  of  the 
anaesthetics  in  general  use.  Its  employment  is  limited  to  operations 
of  short  duration.  It  can  not  be  classed  as  a  practical  anaesthetic, 
since  the  expense,  the  cumbersome  apparatus  for  administration,  and 
its  transient  effects  unfit  it  for  general  use.  It  is,  however,  often 
employed  where  the  presence  of  cardiac  or  other  organic  diseases  con- 
tra-indicate  the  use  of  ether  or  chloroform. 

Inhalers. — The  variety  of  inhalers  for  administering  anaesthetics  is 
large.  It  is  no  part  of  my  intention  to  discuss  the  comparative  virtues  of 
the  various  forms  ;  but  rather  to  select  those  in  common  use,  and  aid  the 
general  practitioner  residing  at  a  distance  from  the  basis  of  surgical  sup- 
plies to  extemporize  at  least  one  which  will  meet  the  pressing  indications. 

The  simplest  method  of  administering  any  anaesthetic,  and  the  one 
generally  employed  with  chloroform,  is  by  moistening  a  towel  or  nap- 
kin. In  the  case  of  ether,  this  is  very  unsatisfactory  ;  inasmuch  as  it 
involves  an  unnecessary  expenditure  of  time  and  of  ether,  and  produces 
a  less  satisfactory  anaesthesia  than  any  other  method.  There  are  other 
pertinent  objections  to  it,  but  those  already  mentioned  are  of  suffi- 
cient weight  to  dismiss  its  further  consideration. 

The  simplest  form  of  an  ether  cone,  or  inhaler,  is  the  one  that  has 
been  for  a  long  time  in  common  use  in  many 
of  the  hospitals  of  this  city  (Fig.  2). 

The  method  of  its  construction  is  simple, 
and  the  materials  employed  are  always  accessi- 
ble. A  sheet  of  paper  of  strong  texture,  or, 
three  or  four  layers  of  an  ordinary  newspaper, 
two  feet  in  length  and  eighteen  or  twenty 
inches  in  width,  together  with  a  strong  piece 
of  cloth,  the  dimensions  of  which  shall  exceed 
those  of  the  paper  two  or  three  inches,  and  a  IG'  —  ^n^  paper 
dozen  ordinary  pins,  are  all  that  is  required  to 

construct  it.  Place  the  cloth — a  towel  is  usually  employed — and  the 
paper  on  a  table,  with  the  paper  uppermost  ;  fold  them  in  the  middle  of 
their  long  diameter,  which  will  bring  the  cloth  on  the  outer  surfaces  and 
the  paper  within.  Then  fold  them  in  the  short  diameter,  the  length  of 
the  fold  corresponding  to  the  distance  from  the  symphysis  mentis  to 
the  root  of  the  nose  of  the  patient ;  when  thus  folded,  pin  the  outer 
and  inner  extremities  firmly  through  the  whole  texture  of  the  sides, 
using  care  that  the  pins  be  so  placed  that  they  will  not  stick  in  the 
patient's  face,  or  in  the  hands  of  the  administrator  of  the  anaesthetic. 
Several  pins  are  now  to  be  passed  through  all  the  textures  in  various 
situation-  to  hold  them  firmly  together.  One  end  of  this  lube  must 
now  be  closed,  which  is  easily  and  quickly  accomplished  by  turning 


8 


OPERATIVE   SURGERY. 


inward  its  borders,  and  securely  pinning  them  to  each  other.  It  is 
better  to  close  the  end  corresponding  to  the  free  extremities  of  the 
material,  thereby  giving  a  firmer  basis  to  the  cone.  Into  the  top  of 
the  cone  is  then  crowded  a  good-sized  sponge,  or  a  piece  of  coarse- 
textured  cloth,  always  observing  that  it  be  beyond  the  reach  of  the 
nose  and  face  of  the  patient.  Absorbent  cotton  or  several  layers  of 
muslin  may  be  interposed  between  the  surfaces  of  the  upper  end,  in- 
stead of  their  being  closed  by  turning  and  pinning  as  just  described, 
when,  if  this  material  be  now  confined  in  position  by  means  of  pins, 
and  the  end  covered  with  a  layer  of  thin  gauze,  the  ether  can  then  be 
poured  upon  the  interposed  material  and  administered  without  remov- 
ing the  cone  from  the  face.  It  likewise  admits  the  requisite  amount 
of  air.  The  advantages  which  this  simple  inhaler  possess  over  the  per- 
manent and  more  expensive  ones  are  quite  numerous.  It  can  not  be 
damaged  by  the  patient,  nor  will  the  face  be  bruised  by  its  borders 
during  his  struggles  ;  it  is  a  temporary  affair,  and  therefore  need  never 
be  used  a  second  time — a  fact  which  is  obviously  of  considerable  im- 
portance in  a  fastidious  and  hygienic  sense.  It  does  not,  however, 
admit  of  the  easy  regulation  of  the  amount  of  ether  to  be  given,  nor 
the  amount  of  air  to  be  admitted  ;  it  is  also  liable,  unless  care  be  used 
in  replenishing  it  with  ether,  to  permit  the  anaesthetic  to  flow  into  the 
eyes  and  upon  the  face  of  the  patient ;  in  addition,  the  air-space  is 
almost  invariably  contracted  during  the  struggles  of  the  patient ;  yet 
these  are  objections  which  can  be  easily  surmounted  by  a  requisite 
amount  of  caution.  The  amount  of  ether  required  with  this  appara- 
tus is  less  than  if  a  napkin  be  used  alone,  while  it  exceeds  that  em- 
ployed in  the  more  perfect  inhalers. 

AIMS'  Inhaler,  which  consists  of  a  fenestrated  metallic  frame-work 


Figs.  3,  4. — Allis'  inhaler. 

for  the  support  of  cloth  partitions,  surrounded  by  an  adjustable  leather 
or  rubber  covering,  is  simple,  efficient,  portable,  and  can  be  quite 
easily  cleansed  (Figs.  3  and  4).     Its  advantages,  briefly  stated,  are  the 


GENERAL   CONSIDERATIONS. 


following  :  It  allows  a  free  admission  of  air  from  above,  which  becomes 
saturated  with  ether  ;  the  evaporating  surface  is  great,  causing  thereby 
a  rapid  vaporization,  which  hastens  anaesthesia  and  saves  ether ;  the 
ether  can  be  replenished  through  the  top, 
which  obviates  the  necessity  of  removing 
the  inhaler  and  interrupting  the  adminis- 
tration. The  cloth  partitions  can  be  read- 
ily changed  whenever  propriety  and  clean- 
liness demand  it. 

The  inhalers  of  Lente,  Squibb,  Noyes, 
and  others,  are  all  serviceable,  and  whoever 
possesses  either  of  them  can,  so  far  as  the 
apparatus  is  concerned,  administer  ether 
■with  safety.  It  is  not  necessary  to  the  safe- 
ty of  the  patient  that  any  one  of  them  be 
employed.  It  is,  however,  necessary  to  the 
safety  of  the  patient,  no  matter  which  one  FlG-  5--Lente's  modified  inhaler, 
be  used,  that  the  administrator  of  the  anaesthetic  shall  rely  more  upon 
his  knowledge  of  the  principles  governing  its  administration  than  upon 
the  mechanism  of  the  apparatus.  With  a  proper  knowledge  of  these  prin- 
ciples, it  matters  but  little  whether  one  or  another  form  of  inhaler  be  used. 
Lente 's  Modified  Inhaler  (Fig.  5). — When  this  is  to  be  used,  either 
a  piece  of  old  muslin,  lint,  or  a  suitable  amount  of  cotton  batting  can 

be    confined    in 
position   at   the 
top  by  a  wire  or 
whalebone     fas- 
tening. The 
amount    of    air 
admitted  can  be 
easily  regulated 
by    the    adjust- 
ment of  the  stopper  at  the  top,  and  the 
ether  can  be  poured  in  at  this  situation  if  it 
be  undesirable  to  remove  the  apparatus  from 
the  face. 

Clover's  Inhcder  (Fig.  6)  consists  of  a  re- 
ceptacle holding  two  ounces  of  ether — a 
mouth-piece  cushioned  with  inflated  rubber 
fitting  closely  over  the  patient's  nose  and 
mouth,  and  connected  with  the  ether  recep- 
tacle in  such  a  manner  that  the  amount  of 
ether  inhaled  may  be  increased  or  diminished 
at  will,  and  a  rubber  bag  which  receives  the  expired  air  charged  with 
ether  vapor. 


Fio.  G. — Clover's  inhaler. 


10 


OPERATIVE  SURGERY. 


Fig.  V. — Squibb's  inhaler. 


The  advantages  claimed  for  this  inhaler  are  :  the  patient  can  be 
anaesthetized  in  a  very  short  time  ;  the  depression  of  the  system  is  not 
so  great ;  the  patient  recovers  consciousness  more  quickly  and  does  not 
feel  the  effects  of  ether  so  long  as  with  the  plain  ether  inhalers.  The 
amount  of  ether  to  be  inhaled  is  graduated  by  turning  the  receptacle  : 
when  turned  on  0,  no  ether  is  inhaled  ;  when  at  1,  %  of  the  usual 
amount ;  at  2^>  the  usual  amount ;  at  3f,  and  at  F  the  full  amount  is 
inhaled.  Thus  the  quantity  of  ether  administered  can  be  increased  or 
diminished  during  the  operation. 

Another  important  point  is,  that  there  is  so  little  ether  consumed 

that    the    inhaler    is 
.j^l^Bi^^^  .^•■'■^    very  valuable  for  use 

M&         ^^IIm*..  ^BsHf^§g&    m    hospitals  and   in 

the  field. 

SquiWs  Inhaler 
(Fig.  7).— This  con- 
sists of  an  hour-glass- 
shaped  muslin  bag, 
one  end  of  which  is 
cut  off  to  fit  the  face 
of  the  patient.  The  narrow  portion  is  made  to  receive  a  tin  tube  sev- 
eral inches  in  length  and  two  in  diameter ;  the  round  end  serves  the 
purpose  of  an  air-chamber.  When  the  bag  is  to  be  used,  it  should  be 
wetted  with  water  and  thoroughly  squeezed,  to  render  it  only  partially 
pervious  to  the  passage  of  air  or  other  vapor.  Into  the  tin  tube  a 
piece  of  flannel  and  blotting-paper  rolled  together,  each  about  six 
inches  wide  and  eighteen  inches  long,  are  thrust,  after  which  they  are 
saturated  with  ether  ;  or  it  may  be  done  before  their  introduction. 
The  open  end  of  the  apparatus  is  then  placed  over  the  mouth  and 
nose. of  the  patient,  and  the  administration  commences.  One  to  two 
and  a  half  ounces  is  quite  enough  to  properly  anaesthetize  the  patient. 
Noyes'  Inhaler  (Fig.  8). — This  apparatus  is  simple  of  construction. 
It  consists  of  a  flexible  air-chamber  at  one  end  and  a  face-piece  at  the 
other.  Between  the  two  is  a  small  tin  chamber  to  contain  the  ether. 
The  bag  or  air-chamber  is  perforated  by  a  small  hole,  that  allows  the 
entrance  of  a  sufficient  amount  of  air,  which  enters  the  lungs  together 
with  the  ether  at  each  effort  of  inspiration.  The  amount  of  ether 
used  with  this,  is  about  the  same  as  with  the  preceding. 

The  amount  of  ether  required  to  produce  insensibility  depends  upon 
several  conditions,  the  most  important  of  which  are,  the  susceptibility 
of  the  patient,  the  manner  of  administering,  and  the  purity  of  the 
anaesthetic.  Some  persons  can  be  completely  anaesthetized  by  an  ounce, 
and  even  less,  if  it  be  not  wasted  ;  on  the  other  hand,  those  are  occa- 
sionally met  with  who  "  take  ether  badly,"  and  can  not  be  rendered 
quiet  unless  a  large  amount  be  given  ;  rarely,  a  case  is  encountered 


GENERAL   CONSIDERATIONS. 


11 


which  will  not  yield  to  its  influence,  and  the  surgeon  is  forced  to 
desist,  from  fear  of  killing  the  patient.  It  is  not  prudent  to  deter- 
mine in  advance  the  definite  amount  that  will  be  used,  except  pos- 


Fig.  8. — Noyes'  inhaler. 

sibly  in  some  peculiar  cases.  Anaesthesia  is  never  to  be  attempted 
unless  the  surgeon  can  be  certain  he  has  a  sufficient  amount  to  com- 
plete the  operation,  for  nothing  can  be  more  .humiliating  than  to  be 
obliged  to  discontinue  an  operation  for  the  purpose  of  procuring  ad- 
ditional ether.  It  is  not  prudent  to  begin  an  operation  that  requires 
much  time  and  care,  unless  at  least  one  pound  of  ether  be  at  hand. 

Purity  of  the  Ancesthetic. — It  is  important  that  the  anaesthetic  be 
pure,  in  order  that  the  amount  taken  may  be  suitably  judged,  and  a 
proper  interpretation  placed  upon  the  effect  produced.  The  anaes- 
thetics of  Squibb,  of  Brooklyn,  are  generally  considered  to  be  of  a 
superior  quality. 

Dangers  from  the  Use  of  Ether. — The  dangers  attending  the  use 
of  an  anaesthetic  may  be  reduced  to  a  minimum,  provided  proper  at- 
tention be  given  to  the  physical  conditions  recognized  as  contra-indi- 
cating or  requiring  caution  in  their  use,  together  with  a  display  of 
ordinary  care  in  administering.  Before  administering  it,  the  condition 
of  the  heart,  lungs,  brain,  kidneys,  vessels,  etc.,  should  be  ascertained, 
even  though  there  be  no  apparent  evidences  of  disease.  If  they  have 
undergone  organic  changes,  or,  if  the  patient  have  laryngeal  obstruc- 
tion from  any  cause,  be  suffering  from  bronchitis,  or  be  pregnant,  the 
greatest  caution  must  be  employed  in  the  administration,  even  if  it 
be  administered  at  all.  The  degree  of  the  disease,  and  the  condition  of 
the  patient  dependent  thereon,  together  with  the  necessity  of  an  im- 
mediate operation,  and  its  severity,  must  determine  the  advisability 
of  an  anesthetic.  If  the  patient  have  advanced  heart  and  kidney 
disease,  phthisis,  or  aneurism,  it  is  better  to  use  nitrous  oxide; 
chloroform,  &Y6B,  li.is  been  used  under  such  circumstances  instead 
of  ether,   on  account  of  its  causing  less  excitement  and  vomiting. 


12  OPERATIVE   SURGERY. 

The  danger  from  a  full  stomach  is  great,  especially  if  the  ingesta  be 
solid ;  since,  if  vomiting  occur,  the  food  may  be  sucked  into  the 
larynx  and  trachea,  causing  death  by  suffocation ;  moreover,  nausea 
and  vomiting  are  more  frequent  and  persistent  when  the  stomach  is 
partially  filled  with  food.  It  is  impracticable  to  lay  down  all  the 
important  relations  existing  between  the  use  of  an  anaesthetic  and 
the  various  complications  that  may  exist  as  contra-indications.  The 
surgeon  must  be  largely  controlled  by  the  circumstances  surrounding 
each  individual  case.  If  it  be  determined  to  administer  ether  or  chloro- 
form to  a  patient  suffering  from  a  debilitated  heart,  the  latter's  action 
must  be  strengthened  by  the  administration  of  digitalis  some  days 
prior  to,  as  well  as  by  stimulants  during  the  operation.  If  the  pa- 
tient have  laryngeal  obstruction,  from  spasm  of  the  glottis  or  other 
causes,  the  pungency  of  the  ether,  and  spasm  of  the  respiratory  mus- 
cles, when  added  to  the  already  lessened  area  of  the  respiratory  chink, 
and  the  diminished  aeration  of  the  blood  resulting  therefrom,  may  be 
often  sufficient  to  produce  rapid  unconsciousness  and  impending  death 
from  asphyxia.  In  my  opinion,  chloroform  is  the  better  ansesthetic 
under  such  circumstances. 

How  to  Prepare  a  Patient  for  Anaesthesia. — First.  Inform  your- 
self of  the  state  of  the  brain,  heart,  lungs,  kidneys,  vessels,  etc. ;  if 
disease  be  found,  inform  the  patient  or  the  friends  of  the  additional 
dangers  incurred. 

Second.  Count  the  pulse  and  respiration,  noting  the  character  of 
each,  and  making  due  allowance  for  the  excitement  dependent  upon 
surrounding  circumstances.  These  observations  will  be  far  more  valu- 
able if  they  have  been  taken  some  time  prior  to  the  immediate  opera- 
tion. 

Third.  See  that  no  solid  food  has  been  taken  for  at  least  six  to 
eight  hours  before  ;  if  so,  evacuate  the  stomach  by  means  of  a  simple 
and  rapid  emetic.  The  practical  way  of  having  the  stomach  in  a 
proper  condition  is  to  omit  the  meal  preceding  the  operation.  If  the 
time  be  too  long  for  this,  a  glass  or  two  of  milk  five  or  six  hours  before 
will  meet  the  indications. 

Fourth.  Eemove  all  false  teeth  from  the  mouth,  or  whatever  else 
might  fall  into  the  larynx. 

Fifth.  Loosen  all  constricting  bands  which  surround  the  abdomen, 
chest,  and  throat. 

Sixth.  Cause  the  evacuation  of  the  contents  of  the  bladder  and 
rectum  ;  this  will  often  prevent  the  soiling  of  the  clothes  and  the 
patient. 

Seventh.  Place  the  patient  upon  the  back,  with  the  head  and 
shoulders  slightly  raised  ;  neck  not  bent. 

Eighth.  If  the  patient  have  a  beard,  wet  it  to  prevent  the  rapid 
escape  of  the  ether  through  it. 


GENERAL   CONSIDERATIONS. 


13 


Ninth.  Adjust  windows  and  doors  to  admit  fresh  air,  without  ex- 
posing the  patient  to  a  draught. 

Tenth.  Disarm  the  patient  of  all  fears  of  danger  attending  the  use 
of  the  anaesthetic. 

The  assistant  who  is  to  administer  the  anaesthetic  should  hare  at 
his  convenience  a  basin,  a  towel,  and  a  tenaculum  or  forceps.  The 
first  for  the  reception  of  the  dejections  from  the  stomach  ;  the  towel 
to  remove  the  saliva,  etc.,  from  the  mouth  and  face  ;  the  tenaculum 
or  forceps,  to  pull  forward  the  tongue  if  it  fall  backward  over  the 
glottis  (Fig.  9). 

It  is  recommended,  and  with  much  force,  to  administer,  hypo- 


Fig.  9. — Drawing  the  tongue  forward. 


dermically  or  otherwise,  a  dose  of  morphia  an  hour  or  so  before  anaes- 
thesia is  to  be  commenced.  It  quiets  the  nervous  excitement  of  the 
patient,  reduces  the  amount  of  ether  otherwise  necessary,  and  prolongs 
its  effect,  lessens  the  tendency  to  nausea  and  vomiting,  and  diminishes 
shock.  Moderate  inebriation  has  been  produced  immediately  in  ad- 
vance of  an  operation  by  giving  brandy  or  whisky,  and  for  substan- 
tially the  same  reasons. 

Method  of  Administering  Ether. — This  will  depend  somewhat  upon 
the  variety  of  inhaler  used  ;  if  it  be  of  ordinary  construction,  com- 
mence by  pouring  a  small  amount  (an  ounce  or  so)  into  or  upon  the 
inhaler,  and  adjust  it  so  that  a  good  volume  of  air  shall  mingle  with 
the  ether  for  the  first  few  moments  of  the  administration.     After  the 

36  of  pungency  has  somewhat  subsided,  the  patient  should  be  told 
to  "cough,"  "breathe  deeply,"  at  the  same  time  the  fresh  air  is  to 
be  quite  rapidly  excluded.  The  patient  soon  becomes  oblivious,  and 
may  be  fully  anaesthetized  without  further  trouble.  This  is  recog- 
nized by  the  insensibility  of  the  conjunctiva,  or,  what  is  better,  a  re- 
laxed muscular  system,  which  is  ascertained  by  noting  the  absence  of 
any  resistance  to  flexing  or  extending  the  extremities.     If  an  extremity 


14 


OPERATIVE   SURGERY. 


be  raised  from  the  bed,  it  will  fall  directly  downward  and  lie  motion- 
less. Stertorous  breathing  is  likewise  a  concomitant  of  complete  anaes- 
thesia. More  often,  however,  the  patient  will  be  seen  to  pass  through 
the  three  distinct  stages  of  anaesthesia,  which  will  vary  in  their  length 
and  manifestations,  according  to  his  peculiarities.  The  attention  of  the 
administrator  of  the  anaesthetic  should  always  be  directed  to  the  char- 
acter of  the  respiration  and  pulse,  the  color  of  the  surface  and  its  tem- 
perature. The  respiration  is  often  temporarily  arrested  or  impeded  by 
the  tonic  stage,  causing  marked  cyanosis.  This  is  quite  readily  relieved 
by  making  sudden  and  forcible  pressure  in  the  epigastrium,  or  slap- 
ping the  chest  with  the  naked  hand  or  a  wet  towel.  The  respiration 
may  be  obstructed  or  prevented,  at  any  period  of  anaesthesia,  by  for- 
eign bodies  in  the  larynx  and  trachea,  such  as  false  teeth,  vomited 
matter,  etc.  In  complications  of  this  character,  the  obstructing  agent 
must  be  removed  immediately  or  death  will  ensue,  unless  tracheotomy 
be  performed.  The  glottis  may  become  stopped  by  the  falling  back- 
ward of  the  tongue  ;  this  usually  occurs  during  the  stage  of  complete 
anaesthesia,  and  is  to  be  instantly  remedied  by  drawing  the  tongue 
forward  by  the  aid  of  a  tenaculum,  or  dry  towel,  or  forceps. 

If  the  jaw  be  pressed  forward  during  the  administration  of  the 
anaesthetic  by  the  administrator  (Fig.  10),  the  muscular  attachments 

of  the  base  of  the 
tongue  are  sepa- 
rated, and  its 
base  depressed 
and  drawn  for- 
ward. 

The  treat- 
ment for  the  re- 
lief of  poison- 
ing, due  either 
to  an  overdose 
of  ether  or 
chloroform,  is 
substantially 
the  same.  Suc- 
cessful treat- 
ment will  depend  not  only  upon  the  presence  of  mind  of  the  sur- 
geon, but  upon  the  precautionary  preparations  which  have  been  made 
for  such  a  contingency,  as  well  as  the  rapidity  and  force  with  which 
the  remedies  are  applied. 

The  anaesthetic  must  be  stopped  at  once  ;  the  head  lowered  and 
the  tongue  pulled  forward  ;  windows  and  doors  opened  to  admit  fresh 
air ;  artificial  respiration  (Figs.  11  and  12)  ;  flagellation  of  the  face  and 
chest  by  towels  wet  with  cold  water  ;  hypodermic  injections  of  brandy, 


Fig.  10. — Pressing  the  jaw  forward. 


GENERAL   CONSIDERATIONS. 


15 


whisky,  or  ammonia  ;  inhalation  of  nitrite  of  amyl,  and  the  use  of  elec- 
tricity employed.  It  is  not  intended  that  these  remedies  shall  be  used 
in  the  order  mentioned;  but  the  surgeon  and  his  assistants  will  find 
their  time  and  thoughts  occupied  in  carrying  them  into  execution — 
such  of  them  as  may  admit  of  instant  application.     Under  no  con- 


Fig.  11. — Artificial  respiration — first  movement. 

sideration  must  the  efforts  of  resuscitation  be  allowed  to  flag,  or 
be  stopped,  until  every  hope  of  saving  the  life  has  some  time  since 
passed.* 

Intestinal  Etherization. — Since  the  appearance  in  the  "  Lyon  medi- 
cal" of  March  30,  1884,  of  M.  Molliere's  article,  calling  the  attention 
of  the  profession  to  the  feasibility  of  etherization  by  the  rectum  and 
setting  forth  the  advantages  to  be  gained  thereby,  not  a  few  promi- 
nent members  of  the  profession  have  made  trial  of  it.  This  mode 
of  administration  is  a  simple  one.  The  ether  is  put  into  a  bottle  of 
suitable  size — holding  four  or  five  ounces — with  which  a  rubber  tube 
of  convenient  length,  terminating  in  a  nozzle,  is  connected.  The  bot- 
tle containing  the  ether  is  placed  in  water  of  a  temperature  of  120°  to 

*  In  performing  artificial  respiration  the  movements  should  he  done  slowly  and  with  a 
regularity  similar  to  the  normal  act  of  breathing.  To  move  the  arms  upward  and  down- 
ward with  the  rapidity  of  a  pump-handle  is  irrational  and  inoperative;  yet,  under  the  in- 
fluence of  exciting  surroundings,  such  attempts  at  resuscitation  are  not  infrequently 
made. 


16 


OPERATIVE   SURGERY. 


140°  Fahr.,  and  the  nozzle  inserted  into  the  rectum  of  the  patient. 
The  ether  vapor  resulting  from  the  ebullition  passes  through  the  tube 
into  the  rectum  and  is  absorbed  by  the  intestinal  mucous  membrane. 
An  apparatus  that  is  especially  devised  for  the  rectal  administration 
(Fig.  13)  simplifies  the  procedure  somewhat.  The  advantages  claimed 
for  this  method  by  Molliere  are  not,  as  yet,  verified  by  American  sur- 
geons. At  the  present  time,  therefore,  this  method  can  not  be  said  to 
equal  the  older  one,  except,  perhaps,  for  operations  about  the  face,  or 
when  ether  is  contra-indicated  on  account  of  the  irritation  it  causes 
the  mucous  membranes  of  the  respiratory  apparatus,  especially  if  they 
be  diseased.  And,  even  under  these  conditions,  the  number  of  fatal 
cases  already  reported  as  due  to  its  use  are  evidence,  as  yet,  of  the 
greater  safety  of  the  old  plan. 

It  is  not  unlikely  that  it  may  prove  serviceable  in  intestinal  obstruc- 


Fig.  12. — Artificial  respiration — second  movement. 


tion  due  to  invagination,  inasmuch  as  the  distention  and  relaxation  of 
the  intestinal  walls  which  it  causes  may  overcome  their  abnormal  rela- 
tions. 

Local  Anaesthesia. — Although  there  are  numerous  agents  in  use 
for  this  purpose,  ether  possesses  the  greatest  number  of  practical  ad- 
vantages. The  following  instrument  (Fig.  14)  is  the  one  commonly 
used  for  purposes  of  local  anaesthesia,  and  is  employed  in  those  minor 


GENERAL    CONSIDERATIONS. 


17 


operations  which  can  be  quickly  done.  The  pain  that  follows  the  re- 
turn of  sensibility  to  the  benumbed  parts  is  often  more  severe  and  pro- 
longed than  the  ininie- 
diate  suffering  from  the 
operation  without  its 
use.  The  tissues  should 
not  be  frozen,  but  be- 
numbed ;  since  to  freeze 
them  increases  the  pain 
and  retards  repair. 

Cocaine.  —  Solutions 
of  this  important  drug 
can  be  employed  both 
hypodermically  and  en- 
dermically  in  many  mi- 
nor surgical  operations. 
Ten  to  twenty  drops  of 
a  five-per-cent.  solution 
injected  at  the  site  of 
the  operation  will  usual- 
ly, in  a  few  minutes, 
render  the  part  insensi- 
ble to  pain.  It  can  be 
applied  to  mucous  sur- 
faces, like  those  of  the 
nose   and   pharynx,    by 

means  of  a  spray.     It  is  sometimes  employed  in  the  urethra  to  obvi- 
ate  the  pain  and  irritation  incident  to  the  passage   of   instruments 
into  this  canal.     It  is  proper  for  me  to  state  in  this  connection,  how- 
ever,    that     it 
should  never  be 
employed        in 

>any  instance 
when  the  sen- 
sations of  the 
patient  are  nec- 
essary b)  guide 
the  operator  in 
his     action. 

There  is  reason  to  believe  that  even  a  small  doc  may,  in  rare  in- 
stances, cause  alarming  symptoms  of  depression;  still,  it  eepma  to 
be  proved  thai  its  unfavorable  constitutional  effect  may  be  obviated, 
while  it-  local  effect  ie  increased  and  prolonged,  by  obstructing  the 
return  circulation  from  the  part  to  nrhich  it  bas  been  applied. 

2 


Apparatus  for  intestinal  etherization. 


r-1 


Via.  1  I.— Richardson' J  atomizer. 


18 


OPERATIVE   SURGERY. 


Fig. 


15. — Scalpels 
touries. 


INSTRUMENTS   NECESSARY   FOR   THE    PERFORMANCE   OF   OPERATIONS. 

The  instruments  necessary  for  the  performance  of  an  operation 
must,  of  necessity,  be  regulated  by  its  magnitude  and  nature.  They 
can,  however,  for  the  sake  of  brevity,  be  di- 
vided into  those  in  general  use,  and,  those  for 
special  purposes.  The  ones  in  general  use  in- 
clude scalpels  and  bistouries  of  various  forms 
(Fig.  15),  thumb-forceps,  grooved  directors, 
and  scissors.  Those  for  special  purposes  are 
used  in  performing  the  operations  which,  in 
most  instances,  caused  their  creation.  These 
will  be  considered  in  connection  with  the 
operation  to  which  they  are  particularly 
adapted. 

Method  of  Holding  the  Scalpel. — Three  po- 
sitions are  commonly  recommended,  each  of 
which  is  subdivided  into  two.  The  basis  of 
the  positions  rests  upon  the  manner  of  hold- 
ing the  ordinary  table-knife,  the  pen,  and  the 
and   Bis-  yiolin-bow. 

Figs.  16  and  17  represent  the  subdivisions 
of  the  first  position  ;  they  indicate  that  force  or  firmness  are  desired. 
Figs.  18  and  19  represent  the  subdivisions  of  the  second  position.  These 
are  taken  when  quick,  delicate,  and  precise  movements  are  required. 
Figs.  20  and  21  are  the  subdivisions  of  the  third  position,  and  are  em- 
ployed when  caution  is  used  in  conjunction  with  delicacy  in  cutting. 

These  positions  are  more  essential  to  graceful  than  to  successful 
operating. 

Thumb  -  Forceps  (Fig.  22)  are 
used  in  connection  with  the  scalpel 
or  scissors.  They  are  employed  to 
pick  up  tissues  like  the  fascia,  etc., 
which  are  to  be  incised  at  the  point 
grasped  for  the  purpose  of  inserting 
the  grooved  director.  The  scalpel 
or  bistoury  should  be  held  at  near- 
ly a  right  angle  to  the  forceps  when 
the  incision  is  made,  especially  when 
important  structures  lie  immediate- 
ly beneath  (Fig.  23). 

The  Grooved  Director  (Fig.  24)  is  used  to  raise  the  tissues  which 
are  to  be  divided  with  caution.  It  should  be  five  or  six  inches  in 
length,  depending  upon  the  length  of  the  incision  and  the  depth  of 
the  wound  into  which  it  is  to  be  inserted  ;  flexible,  with  a  broad  ex- 


Fig.  16. 


GENERAL   CONSIDERATIONS. 


19 


tremity  to  grasp,  and  a  pocket  at  the  end  of  the  groove  to  arrest  the 
point  of  the  knife  or  scissors.     It  should  not  be  pushed  beyond  the 


Fig.  17. 


extremities  of  the  external  incision,  because  of  the  danger  of  making 
pockets  in  the  soft  parts,  which  will  impede  drainage.     The  tissues 


FlO.  18. 


Fig.  19. 


raised  upon  the  director  must  not  be  divided  beyond  the  angles  of  the 
external  incision.  Care  should  be  taken  when  the  director  is  passed 
between  a  serous  membrane  and  its  superimposed  fascia  that  the  mem- 


fia.  2>>. 


Fig.  2i. 


20 


OPERATIVE   SURGERY. 


brane  does  not  fold  over  the  advancing  extremity,  thereby  causing  it 
to  be  punctured  or  divided  by  the  knife  or  scissors. 

The  Scissors. — They  are  used  as  a  substitute  for  the  scalpel  in  in- 
cisions of  great  depth,  combined  with  limited  space  and  a  necessity 


Fig.  22. — Thumb  forceps. 

for  caution.    Less  hemorrhage  follows  their  use  than  from  the  scalpel, 
owing  to  the  crushing  nature  of  their  force.     They  should  be  more  or 


Fig.  23. — Nicking  fascia. 

less  angular,  to  accommodate  them  to  the  depth  of   the   operation- 
wound  (Figs.  25  and  26). 

Incisions. — The  varieties  of  incisions  are  numerous,  and  are  named 
from  the  shape  which  they  take.  The  outlines  of  incisions  are  con- 
trolled very  largely  by  the  underlying  anatomy,  the  desire  to  secure 
good  drainage,  and  to  avoid  disfiguring  the  patient.  There  is  a 
greater  danger  of  making  an  incision  too  short  than  too  long  ;  and 
of  the  two,  the  former  is  the  greater  evil.     A  long,  deep,  clean-cut 


Fig.  24. — Grooved  director. 


incision  will  drain  better  and  heal  more  quickly  than  a  short  deep  one 
bounded  by  tissues  which  have  been  disturbed  by  the  efforts  to  accom- 
plish a  definite  purpose  within  a  too  limited  space.  The  various 
forms  of  incisions  will  appear  in  connection  with  the  operations  to 
which  they  are  applicable. 


GENERAL   CONSIDERATIONS. 


21 


Fig.  26. — Straight  probe-pointed  scissors. 


Fig.  25. — Curved  scissors. 


Instruments  should  be  Plain. — All  instruments  associated  with 
surgery  should,  when  practicable,  be  constructed  in  a  plain  and  sub- 
stantial manner.  The  handles  and  shanks  of  the  knives  should  be 
smooth  and  closely 
fitted,  or,  what  is  bet- 
ter, the  entire  instru- 
ment should  be  made 
of  metal  and  be  highly 
polished.  The  inequal- 
ities of  instruments 
tend  to  catch  impuri- 
ties, and  should  never  be  tolerated  when  they  but  serve  to  embellish 
the  implement. 

Receptacle  for  Instruments. — It  is  better  that  all  instruments  be 
made  aseptic  before  they  are  employed  ;  for  this  purpose,  a  shallow 
tray  of  suitable  dimensions  should  be  filled  with  an  antiseptic  fluid, 
and  the  instruments  immersed  therein  for  an  hour  or  two  before 
they  are  used.  This  tray,  with  the  contents,  should  be  placed  at  a 
convenient  distance,  in  order  that  the  instruments  may  be  taken  di- 
rectly from  it  when  needed.  If  they  are  to  be  again  required,  they 
should  be  returned  to  the  tray  as  soon  as  used. 

Operating-Table. — The  patient  should  always  be  placed  upon  a 
regular  operating-table,  or  an  ordinary  table  of  sufficient  height  to  suit 
the  convenience  of  the  surgeon.  To  operate  upon  a  bed  or  lounge,  as 
is  often  done,  not  only  cripples  the  resources  of  the  surgeon,  but  robs 
him,  too  often,  of  a  suitable  light,  to  say  nothing  of  the  soiling  of  the 
bedding.  There  are  numerous  styles  of  operating-tables,  many  of  which 
an;  of  very  ingenious  construction  ;  they  are,  however,  much  better 
Baited  for  hospital  than  private  practice.  The  ordinary  table,  covered 
by  an  old  quilt  and  rubber  cloth,  will  meet  all  common  indications. 

Empty  Vessels. — There  should  always  be  a  good  supply  of  empty 
pails  and  basins  to  receive  the  waste-water,  soiled  linen,  amputated 
part-,  etc.  At  least  one  empty  basin  should  be  provided  to  receive  the 
Boiled  sponges,  otherwise  they  may  fall  upon  the  floor  or  table,  and  be 
stepped  upon  or  lost.     Two  pails  of  antiseptic  water,  one  hot  and  one 


22  OPERATIVE   SURGERY. 

cold,  should  be  provided  to  wash  the  sponges  during,  and  the  hands 
and  instruments  after  the  operation  ;  for  the  latter  purpose  hot  water 
is  better. 

Clean  Towels  and  Old  Linen. — An  abundance  of  these  should  be  at 
hand,  and  for  obvious  reasons.  However,  if  the  operation  is  being  con- 
ducted on  strict  antiseptic  principles,  they  must  not  be  used  until 
after  the  wound  is  dressed ;  unless  they  be,  at  first,  saturated  with 
an  antiseptic  solution. 

Antiseptic  Solutions  must  be  abundantly  provided  and  used  in 
the  place  of  water,  by  all  who  are  obliged  to  handle  the  undressed 
wound  or  the  instruments  which  are  to  be  brought  in  contact  with  it. 
Carbolic  acid  is  more  often  used  than  all  the  others  combined.  It  is 
cheap,  efficient,  and  easily  obtained.  Two  solutions  are  commonly 
employed  :  one  called  the  weaker,  and  the  other  the  stronger  solution. 
The  latter  can  be  made  in  the  following  manner  : 

Carbolic-acid  crystals 1  part. 

Alcohol 1     " 

Water 20  parts. 

This  is  employed  to  wash  the  wound  before  and  subsequent  to  an 
operation.  It  is  used  for  the  spray,  and  to  purify  all  the  instruments  ; 
it  may  be  used  to  wash  the  hands  prior  to  operating,  but  this  strength 
is  objectionable,  since  it  often  benumbs  the  keen  sense  of  touch  and 
otherwise  causes  them  to  feel  disagreeable.  The  weaker  solution  is 
made  by  taking — 

Carbolic-acid  crystals  -. 1  part. 

Alcohol " 1     " 

Water 40  parts. 

This  is  employed  for  the  general  purpose  of  cleanliness,  and  has, 
therefore,  a  somewhat  more  extended  range  of  usefulness. 

Carbolic  acid  is  often  combined  with  oleaginous  substances  in  the 
proportions  of  one  of  the  acid  to  five  or  ten  of  the  substance,  although 
it  is  thought  that  the  antiseptic  power  of  the  acid  is  lessened  if  not 
entirely  prevented,  by  all  such  combinations.  Ligatures  may  be  soaked 
in  these  preparations,  and  lint  be  saturated  with  them  and  applied 
directly  to  the  raw  surfaces.  The  objections  to  carbolic  acid  are  its 
offensive  odor,  and  liability  to  produce  poisoning.  The  former  can  be 
tolerated,  while  the  latter  can  be  prevented  in  nearly  all  instances  by 
not  allowing  the  strong  solution  to  become  confined  within  the  tis- 
sues. Solutions  of  the  chloride  of  zinc  (1-15),  iodine  (1-500),  sulpho- 
carbolate  of  zinc  (1-80),  bichloride  of  mercury  (1-2,000  to  1-10,000), 
biniodide  of  mercury  (1-2,000),  a  saturated  solution  of  boracic  acid, 
sulphurous  acid,  pure  or  diluted  (1-2),  or  a  saturated  solution  of 
iodoform  and  ether,  are  employed  as  washes,  or  modified  applications 
for  wounded  surfaces.  The  objectionable  odor  of  iodoform  may  be 
masked  by  adding  to  it  one  tenth  of  its  weight  of  thymol,  Tonka 


AGENTS  FOR   CONTROLLING   HEMORRHAGE.  23 

bean,  or  balsam  of  Peru.  Tbe  solutions  of  tbe  bicbloride  of  mercury 
(1-2.000  to  1-10,000)  are  deserving  of  especial  consideration,  inasmuch 
as  they  bid  fair  to  supplant  the  carbolic-acid  solutions  as  antiseptic 
agents ;  like  the  former,  they  are  cheap,  accessible,  and  efficient ;  un- 
like carbolic-acid  solutions,  however,  they  are  inoffensive,  more  in- 
nocuous, and  do  not  benumb  the  sensations  of  the  operator.  They 
should  be  freshly  prepared  before  using,  and  their  tendency  to  chemi- 
cal transformation  into  the  chloride,  by  exposure,  counteracted  by  the 
addition  of  a  small  amount  of  common  salt.  The  liability  of  mercurial 
poisoning  from  their  use  during  an  operation  is  of  little  practical  im- 
portance. It  is  not  advisable,  however,  to  employ  them  for  the  pur- 
pose of  the  daily  cleansing  of  wounds  of  larger  size,  since  their  con- 
stitutional effects  may  be  produced.  For  this  purpose  they  should  not 
be  used  oftener  than  twice  per  week,  and  then  they  should  be  carefully 
drained  from  the  wound  cavity  and  the  patient  be  rigidly  scrutinized 
to  detect  the  first  manifestation  of  their  constitutional  effects.  Peroxide 
of  hydrogen  is  an  efficient  fluid  for  antiseptic  purposes,  but  its  use  is 
not  practicable  on  account  of  the  difficulty  of  obtaining  it. 

Sponges. — The  variety  known  as  "  surgeons'  sponges  "  are  the  best, 
although  expensive.  The  larger  sponges  of  a  proper  texture  can  be 
cut  into  pieces  of  a  suitable  size,  thoroughly  cleansed  and  disinfected, 
when  they  will  answer  all  purposes.  No  sponge  of  whatever  quality 
should  be  used  till  it  has  been  thoroughly  deprived  of  all  foreign  mat- 
ters and  disinfected.  It  is  a  good  practice  to  select  and  cleanse  a  num- 
ber of  sponges,  and  keep  them  in  a  closed  jar  containing  a  strong  solu- 
tion of  carbolic  acid  or  other  disinfectant  until  needed.  They  should 
not  be  repeatedly  used  ;  it  is  far  more  consistent  with  careful  surgery 
to  get  a  new  supply  in  each  individual  case  than  to  use  them,  even  a 
second  time,  under  the  most  favorable  circumstances. 


CHAPTER   II. 

AGENTS  FOR   CONTROLLING  HEMORRHAGE. 

The  agents  that  arrest  hemorrhage  are  multifarious  and  suited  to 
all  of  it-  phases.  They  may  be  divided  into  the  natural  and  artificial, 
each  of  which  may  be  subdivided  info  the  temporary  and  permanent. 
A  natural  agent  ie  one  interposed  by  nature;  one  which  results  as  a 
natural  consequence  from  an  interference  with  the  inherent,  tenden- 
or  endowments  of  the  vessels  and  blood.  The  principal  tempo- 
rary natural  hemostatics  consist  of  the  contraction  and  retraction  of 


24 


OPERATIVE   SURGERY. 


the  inner  coat  of  a  divided  or  ligatured  vessel,  accompanied  by  the  for- 
mation of  a  blood-clot  within  it.  The  contraction  and  retraction,  to  be 
perfect,  require  that  the  coats  of  the  vessels  be  not  diseased,  and  that 
they  be  properly  constricted  by  the  ligature  or  other  force.  The  forma- 
tion of  the  internal  clot  requires  that  a  suitable  distance,  depending  up- 
on the  size  of  the  vessel,  shall  exist  between  the  ligature  and  the  collat- 
eral branches  ;  also,  that  the  coats  of  the  vessel  be  not  greatly  diseased. 
These  points  are  of  importance  in  determining  the  site  and  feasi- 
bility of  an  operation.  The  permanent  natural  agent  is  the  organiza- 
tion and  contraction  of  the  clot,  thereby  completely  occluding  the 
artery  ;  this  result  will  depend  largely  upon  the  condition  of  the  coats 
of  the  vessel,  and  has  a  very  important  bearing  upon  the  possibility  of 
that  much  to  be  dreaded  sequel  to  an  operation,  secondary  hemorrhage. 
Artificial  Hemostatics. — This  class  is  always  temporary.  The  fol- 
lowing are  the  well-recognized  ones  in  constant  use  :  Cold,  styptics, 
posture  of  the  injured  part,  bandages  of  various  forms,  digital  and  in- 
strumental pressure  ;  also,  pressure  by  a  simple,  or  a  graduated  com- 
press, acupressure,  torsion,  forceps,  serrefines,  compressors,  cautery, 
etc.  ;  finally,  and  best  of  all,  the  ligature. 

Styptics,  such  as  liquor  ferri  subsulphatis,  tannin,  etc.,  are  fre- 
quently employed  to  check  oozing  ;  hot  water  is  especially  indicated 
when  the  patient  is  debilitated  or  suffering  from  severe  shocks. 
Liquor  ferri  subsulphatis  is  decidedly  objectionable  where  union  by 
first  intention  is  desired,  but  is  very  serviceable  when  an  antiseptic 
styptic  is  required. 

Position. — Elevation  or  flexion  of  a  limb  serves  to  impede  its  cir- 
culation, and  thereby  lessens  the  tendency  to  hemorrhage.    The  reverse 

of  this  principle  directs  us 
to  lower  the  head  in  pros- 
tration from  loss  of  blood. 
Bandages.  —  These 
may  be  divided  into  two 
distinct  classes,  the  ine- 
lastic and  elastic.  The 
inelastic,  or  ordinary 
roller,  is  used  to  check 
capillary  and  venous  ooz- 
ing by  applying  it  firmly 
over  the  bleeding  part. 

The  Elastic  Bandage— 
of  which  Esmarch  is  the 
projector — is  made  of  elastic  webbing  the  width  of  an  ordinary  roller, 
and  of  sufficient  length  to  meet  the  requirements  (Fig.  27).  It  is  to 
be  applied  firmly  in  a  spiral  manner  to  the  limb,  from  the  distal  ex- 
tremity upward  (Fig.  28)  to  a  good  distance  above  the  point  to  be  oper- 


Fig.  27. — Elastic  bandacre. 


AGENTS   FOR   CONTROLLING    HEMORRHAGE. 


25 


Fig. 


;8. — Elastic  bandage 
applied. 


ated  upon,  where  it  is  supplemented  by  a  rub- 
ber cord,  or  strap,  passed  firmly  around  the 
limb  at  this  point,  and  fastened  by  a  clasp  or 
hook  adapted  to  that  special  purpose  (Figs.  29, 
30,  and  31).  The  bandage  is  then  removed  by 
unwinding  it  from  above  downward.  The 
clamp  devised  by  Langenbeck  (Fig.  32)  can 
be  applied  to  the  upper  turns  of  the  bandage, 
or,  the  upper  turns  can  be  tied  together  by  a 
piece  of  an  ordinary  roller  bandage,  after 
which  the  rubber  bandage  is  removed  from  be- 
low upward.  The  independent  cord  or  strap 
can  be  fastened  in  a  similar  manner.  After 
the  removal  of  the  bandages  the  limb  will  have 
a  cadaverous  aspect,  being  entirely  devoid  of 
blood,  and  the  necessary  operation  can  be  per- 
formed and  the  wound  dressed  even  without 
the  least  hemorrhage.  This,  like 
many  other  useful  agents,  has  objec- 
tionable features.  Its  removal  is  often 

followed  by  a  large  amount  of  persistent  oozing  ;  its  applica- 
tion may  force  into  the  circulation  deleterious  elements  which 

will  form  the  basis  of  disease  ; 
it  has  temporarily  paralyzed 
the  part  to  which  it  was  ap- 
plied, and  caused  transient  dis- 
turbances of  the  general  circu- 
lation. These  latter  are  not, 
however,  sufficiently  import- 
ant to  contra-indicate  its  use. 
The  tendency  to  severe  oozing 
is  an  objection  which  must 
stand  against  it  ;  but  its  power 
to  force  improper  products 
from  diseased  or  injured  parts 
into  the  general  circulation  can 
be  obviated  by  omitting  its  ap- 
plication to  those  parts  ;  that 
is,  by  raising  the  limb  and 
ludding  it  till  well  depleted  by 
the  force  of  gravity,  then  ap- 
plying it  to  the  sound  parts, 
above  the  se;it  of  injury  or  dis- 
ease, and  using  t  he  rubber  band 
■i  — Ni.:,i-( '-  oomprexdon  band,  M    before.      The    clastic  ban- 


26 


OPERATIVE    SURGERY. 


dages  can  be  made  to  serve  another  and  very  important  purpose,  that 
of  forcing  into  the  circulation  of  the  trunk  the  blood  in  the  extremi- 
ties in  cases  of  extreme 
prostration  from  hemor- 
rhage. Martin's  bandage 
(Fig.  33)  is  simply  a  rub- 
ber roller,  and  is  used  to 
meet  the  same  indications 
as  the  former.  It  can 
be,  however,  more  readily 
cleaned  than  a  "webbed 
one,  arid  in  this  particular 
is  preferable  to  it.  Solid 
rubber  rings  of  a  suitable 
size  to  pass  firmly  over 
an  extremity  have  been 
used  as  a  substitute  for 
the  rubber  bandage.  In 
connection  with  the  dig- 
its, and  even  the  foot, 
hand,  and  wrist,  they  act 
yet  gained  the  support  of 


Fig.  SO. — Foulis'  fastening  in 
position. 


Pig.  31. — Foulis' 
fastening  with 
rubber  cord. 


quite  well,  but  have  not  a 
the  profession. 

Compresses. — Two  hinds  of  compresses  are  in  com- 
mon use — the  simple  and  the  graduated.  The  former 
consists  of  several  thicknesses  of  cloth,  or  other  suita- 
ble material,  folded  into  small  dimensions  and  placed 
over  the  vessel,  or  upon  the  part  which  it  is  desired  to 
compress,  and  held  in  position  by  a  tightly  drawn 
bandage  or  strip  of  adhesive  plaster. 

The  graduated  compress  may  be  of  the  form  of  an  inverted  pyramid 
or  cone,  and  oblong  (Figs.  34,  35,  and  36).     Its  apex  should  be  firm 

and  unyielding,  to 
give  an  equal  and 
constant  pressure. 
The  whole  arrange- 
ment can  be  made  of 
superimposed  layers 
of  cloth,  antiseptic 
gauze,  or  adhesive 
plaster,  of  a  size  and 
shape  to  symmetri- 
cally form  its  struc- 
ture. It  is  employed 
parts,   and  to  arrest 


Fig.  82. — Langenbeck's  clamp. 

to  press  upon  the  deep-seated  vessels  of  the 


soft 


AGENTS   FOR   CONTROLLING   HEMORRHAGE. 


27 


hemorrhage  from  within  a  deep  wound  or  cavity.  Care  must  be  em- 
ployed in  properly  adjusting  it,  else  it  may  impede  venous  return,  or 
cause  pain  by  pressing  upon  large  nervous  trunks. 

Digital,  pressure  is  the  most  available  of  all  the  pressure  hemo- 


— Murtin'.-  bandage. 


Fig.  34. — Pyramidal  compress. 


statics.  It  is  constantly  at  hand,  and  often  intuitively  seeks  to  arrest 
the  flow  of  blood.  It  is  necessary  only  to  add  to  a  sensitive  finger  and 
a  sensible  brain,  a  knowledge  of  where  and  how  to  apply  the  force,  to 
render  this  form  of  pressure  of  inestimable  value.  The  vessel  should 
be  pressed  against  some  resisting  part  ;  as,  where  it  lies  in  contact 
with  a  bone.  If  the  b  me  be 
deeply  seated,  the  vessel  must 
always  be  pressed  toward  it  (Fig. 
37).  anli  one  in  many 

-.  the  limb  be  grasped  bo  as 
to  bring  the  ends  of  the  fingers 
against  the  vessel  (Fig.  38).  If 
blood  flows  from  an  open  wound, 
direct  pressure  must  be  made 


Fig.  35. — Oblong  compress. 


upon  the  bleeding  points  with  one  hand,  while  the  other  hastens  to 
compress  the  main  artery  above  the  point  of  hemorrhage.  It  is  not 
necessary  to  u.-e  great  force  to  interrupt  the  blood  current  ;  moreover 


Fig.  36. — Conical  con 

to  do  so  tires  the  arm  and  hand,  and  causes  the  patient  much  pain  ; 

just  force  enough  to  interrupt  all  blood  flow.     The  thumb  of 

the  right  hand  is  the  best  digit  to  apply  at  first  :  afterward,  it  may 

relieved  in  various  ways  by  the  aid  of  the  fingers  and  thumbs  of 

those  in  attendan  condary  hemorrhage  be  anticipated,  or  have 


28 


OPERATIVE   SURGERY. 


occurred,  the  proper  point  for  pressure  on  the  hody  or  limb  must  he 
indicated  by  some  indelible  substance,  so  that,  in  case  of  a  sudden  flow, 


Fig.  37. — Digital  compression  of  femoral.         Fig.  38. — Digital  compression  of  brachial. 

any  attendant  can  arrest  it ;  with  this  object  in  view,  all  the  attendants 
must  be  instructed  in  the  details  of  making  pressure,  and  be  thor- 
oughly impressed  with  the  ne- 
cessity of  constant  vigilance  and 
instant  action. 

Vessels  that  are  inaccessible 
to  digital  compression  can  be 
controlled  often  by  the  handle 
of  a  key,  or  by  a  short  crutch  ; 
the  applied  extremity  of  either 
should  always  be  covered  by 
some  soft  material  to  prevent 
injuring  the  vessel. 

Instrumental  Pressure.— Un- 
der this  heading  are  included 
the  various  forms  of  tourniquets 
and  such  other  devices  as  are  not 
directly  connected  with  the  ad- 
justment of  ligatures  to  bleeding 
vessels.  The  tourniquet  in  com- 
Fig.  39.— -Petit's  tourniquet.  mon  use  was  devised  by  Petit, 


AGENTS   FOR   CONTROLLING   HEMORRHAGE. 


29 


and  is  no  doubt  familiar  to  all  (Fig.  39).     It  should  be  cautiously  ap- 
plied, and  so  directed  that  the  pressure  will  compress  the  vessel  against 


Fig.  40. — Tourniquet  applied  to  femoral.  Fig.  41. — Tourniquet  applied  to  brachial. 

the  bone,  when  possible.     A  simple  and  effective  tourniquet  can  be 

extemporized  by  placing  a  roller  bandage  over  the  site  of  the  vessel, 

confining  it  in  position  by  a 

handkerchief    passed    around 

the  arm.     If  the  handkerchief 

be  then  tied  and  twisted   by 

a   stick,   the   circulation    will 

be    effectually   stopped    (Fig. 

43). 

Davy's  Lever  is  an  imple- 
ment devised  by  the  surgeon 
whose  name  it  bears.  It  is 
employed  for  the  especial  pur- 
pose of  controlling  hemorrhage 
in  amputations  at  the  hip- 
joint.  It  is  passed  up  the  rec- 
tum in  the  direction  of  that 
oaoal  a  sufficient  distance  to 
make  pressure  on  the  common 
iliac  artery   on   the  side   from 

which  the  limb  is  to   be  re- 
moved.    The  upper  extremity         Fio. 42.— Kncbel'fl  Improvised  tourniquet. 


30 


OPERATIVE   SURGERY. 


is  then  carried  to  the  right  or  left  sufficiently  to  lie  between  the  bodies 
of  the  lumbar  vertebrae  and  the  psoas-magnus  muscle.  The  lower 
extremity  must  then  be  raised,  to  bring  the  requisite  pressure  upon 
the  vessel  (Fig.  43). 

It  has  been  employed  by  its  designer  and  other  surgeons  with  sig- 


Fig.  4S. — Davy's  lever  applied. 

nal  success.  It  can  be  more  safely  applied  to  the  left  than  to  the  right 
side,  on  account  of  the  left  iliac  artery  being  nearer  to  the  rectum 
than  the  right.  Its  introduction  must  be  preceded  by  an  injection  of 
sweet-oil,  after  which  it  ^nust  be  cautiously  introduced,  and  held  in 
position  by  a  gentle,  though  firm,  pressure.  If  unnecessary  force  be 
used,  it  may  tear  or  perforate  the  gut.  The  instrument  in  question  is 
round,  turned  from  ebony,  and  from  eighteen  to  twenty  inches  in 
length.     The  surface  is   smooth,   and   its   extremities  rounded  ;    its 


AGENTS  FOR   CONTROLLING    HEMORRHAGE. 


31 


largest  diameter  is  about  five  eighths  of  an  inch.  It  can,  be  graduated 
so  that  the  surgeon  will  be  able  to  estimate  the  exact  extent  of  its 
entrance  to  the  bowel.  Its  shape  has  been  variously  modified  to  meet 
the  requirements  suggested  by  its  more  extended  use 

Trendelenburg' 8  Rod. — This  is  likewise  used 
for  the  same  purpose,  but  in  an  entirely  differ- 
ent manner  (Fig.  44).  It  is  passed  through  the 
soft  parts  at  such  a  depth  as  to  include  the  whole 
thickness  of  the  proposed  flap.  A  strong  rubber 
cord  is  then  passed  over  its  extremities  with 
sufficient  force  to  compress  the  vessels  in  the 
tissues  above  it.  The  flap  can  then  be  made  and 
the  vessels  ligatured  without  loss  of  blood,  after 
which  the  rod  is  withdrawn  and  the  remaining 
flap  made  in  a  similar  manner.  The  principle  is 
a  feasible  one,  but  it  has  not  yet  been  enough 
practiced  to  become  an  established  method. 

Acupressure. — This  plan,  as  a  means  of  con- 
trolling hemorrhage,  was  devised  by  Sir  James 
Y.  Simpson,  and  is  used  much  less  in  this  than 
in  foreign  countries.  Acupressure  is  applied  in 
many  modified  ways ;  the  modifications  may, 
however,  be  reduced  practically  to  two  in  num- 
ber :  one,  where  the  pin  is  carried  through  the 
soft  parts  under  the  vessel,  and  the  point  ele- 
vated and  pushed  through  at  an  angle  sufficient 
to  cause  it  to  tightly  close  the  lumen  of  the 
artery. 

If  this  be  not  effective,  additional  pressure 
can  be  made  by  passing  beneath  each  extremity 
of  the  pin  several  turns  of  cotton  yarn  or  of  the 
ordinary  silk  ligature.  This  method  is  often 
employed  to  arrest  hemorrhage  from  small 
branches  in  the  palm  of  the  hand  and  other 
similar  situations,  and  should  be  supplemented 
by  Buck's  pin-conductor  (Fig.  48),  which  is 
ed  beneath  the  vessel  and  out  through  the 
integument  ;  then  the  pin  is  inserted  into  its 
open  extremity  and  carried  through  by  withdrawing  the  needle.     The 

»nd  method  is  the  reverse  of  the  first,  the  pin  resting  upon  and 
pressing  the  vessel  downward  upon  the  deep-seated  tissue,  instead  of 
upward  against  the  superficial  The  distance  from  the  end  of  the  res- 
Bel  at  which  the  pressure  is  ;i|)|>lied  depends  upon  its  size;  if  large, 
within  one-half  inch  ;  if  smaller,  the  distance  can  be  lessened  propor- 
tionately to  it-  size. 


Fig. 


1 


\I 

44.  —  Trendelen- 
burg's rod. 


32 


OPERATIVE   SURGERY. 


Circumclusion,  torsoclusion,  and  retroclusion  are  variations  of  the 
method  of  pin-pressure  produced  either  by  twisting  or  compressiug  the 

caliber  of  the  ves- 
sel.     These  vari- 
ous methods  seem 
to  possess  but  one 
distinct  practical 
advantage      over 
the   occlusion   of 
the    same    chan- 
nels by  catgut  lig- 
ature ;   they  can 
be  more  safely  ap- 
atheromatous  and  other 
various  modifications   of 
The  pins, 


Fig.  45. — Fin  above 
vessel. 


Fig.  46. — Oblique  in- 
sertion of  pin. 


Fig.  47. — Pin  be 
neath  vessel. 


plied  to  vessels  with  brittle  coats  due  to 
changes.  The  minute  description  of  the 
acupressure  can  be  found  in  the  text-books  of  the  day, 
which  are  made  of  gold,  silver,  steel,  and  iron,  are  of  various  lengths  ; 
they  have  glass  heads  and  differently  shaped  points.  A  further  de- 
scription or  an  illustration  is  not  necessary,  since  they  can  be  satisfac- 
torily ordered.  Shawl-pins,  ordinary  pins  and  needles,  can  be  substi- 
tuted, if  the  exigencies  of  the  case  require  it. 

Torsion.  —  Tor- 
sion is  not  as  modern 
a  procedure  as  its 
limited  employment 
would  warrant  the 
belief.  It  consists  in 
thoroughly  isolating 
and  drawing  down 
the  vessel,  seizing  it 
firmly  with  a  pair  of 
forceps,  about  one- 
half  inch  above  its 
extremity,  and  twist- 
ing the  end  several 
times  till  its  resist- 
ance is  overcome  (Fig.  49) 
The  blood  is  then  allowed  to  impinge  upon  the  twisted  portion  be 
fore  the  vessel  is  released,  to  test  the  completeness  of  the  occlusion. 
The  twisting  produces  a  mutilation  and  breaking  up  of  the  coats 
of  the  vessel,  which  occlude  its  caliber,  and  cause  a  rapid  forma- 
tion of  the  internal  clot.  It  is  evident,  if  the  coats  be  diseased 
and  brittle,  that  much  caution  is  necessary  in  twisting  them,  else  a 
good  basis  for  the  occurrence  of  secondary  hemorrhage  will  be  estab- 
lished.    Torsion-forceps,  which  combine  in  one  instrument  the  hold- 


Fig.  48. — Buck's  needle  conductor, 
care  being  taken   not  to  twist  it  off. 


AGENTS  FOR   CONTROLLING  HEMORRHAGE. 


33 


ing  and  twisting  forceps,  are  far  more  convenient  (Fig.  50).  Torsion 
as  a  substitute  for  the  ligature  is  not  considered  with  much  favor  in 
this  country,  except  in  individual 
instances.  It  is  commonly  em- 
ployed, however,  to  check  the 
small  bleeding  points  seen  on  the 
surface  of  freshly  cut  wounds. 

Forceps,  Serrefines,  and  Tenac- 
ula. — Since  these  instruments  are 
closely  associated  in  common  use- 
fulness, they  can  be  spoken  of  in 
connection  with  each  other.  The 
spring-catch  fenestrated  forceps  are 
the  best.  There  are  two  patterns 
of  these  :  Liston's  (Fig.  51),  and 
those  devised  by  Prof.  Hamilton 
(Fig.  52).* 

The  expansion  of  the  fenes- 
trated extremity  carries  the  liga- 
ture around  the  vessel,  rendering 
it  practically  impossible  to  tie  the 
end  of  the  instrument,  as  in  the 
case  of  the  simple  Liston  forceps  (Fig.  53). 

Liston's  mouse-tooth  forceps,  while  they  are  not  suitable  for  the 
common  purpose  of  catching  bleeding  vessels,  are  nevertheless  of  great 


Fig.  4'J. — lorsion  oi  an  artery. 


Fig.  50. — newson's  torsion  forceps. 

service  in  securing  bleeding  points  on  flat  surfaces,  especially  when 

surrounded  by  dense  tissues. 

The  serrefine-forceps  are  of  great  utility  to  control  bleeding  points 

during  an  operation. 
They  can  be  easily  and 
quickly  adjusted,  and, 
by  their  pressure  on  the 
coats  of  the  small  ves- 
sels,   the    necessity  of 

Tic.  51.— Liston's  spring-catch  fenestrated  artery  forceps,  afterward  using  a  liga- 
ture  may  be  obviated. 

They  can  be  used  to  catch  and  control  bleeding  points  to  which  the 

*  The  slide-catch  arterial  forceps  of  Esmarch  arc  strong  and  serviceable,  although 
they  can  not  be  bo  quickly  applied  as  the  snap-catch  varieties. 
3 


34: 


OPERATIVE  SURGERY. 


Fig.  53. — Liston's  mouse-tooth  forceps. 


application  of  a  ligature  is  impossible,  and  even  be  allowed  to  remain 
upon  the  vessel  till  all  danger  of  bleeding  has  subsided.     There  are 

several  varieties  of  these 
instruments.  The  for- 
cep  -  serrefine,  which  is 
the  largest  (Fig.  54)  ;  the 
angular  and  straight,  and 
those  of  Langenbeck 
(Fig.  55).  The  first  are 
admirably  adapted  to  con- 
trolling large  vessels,  and, 
by  their  grasping  and 
self-retaining  forces,  can  be  employed  in  connection  with  other  tissues. 
Dr.  J.  L.  Little,  of  this  city,  devised  a  forcep-serrefine  having  a 
fenestrated  biting  extremity,  re- 
sembling in  all  practical  respects 
the  extremity  of  the  fenestrated 
artery  forceps.  The  one  devised 
by  Gross  (Fig.  57)  can  be  at- 
tached to  the  bleeding  point,  the  handle  unscrewed,  and  the  blades  per- 
mitted to  remain  until  all  danger  of  bleeding  has  ceased.     The  smaller 

ones  (Figs.  55  and  56) 
are  employed  to  catch 
small  bleeding  points. 

Milne's  compressing 
forceps  (Fig.  58)  are 
closely  allied  in  princi- 
ple to  the  serrefine  ; 
they  are  likewise  useful 
for  compressing  the 
smaller  arteries  in  their  course  through  the  soft  tissues,  as  the  coro- 
nary arteries  in  the  operation  for  hare-lip.  Langenbeck's  are  also  ad- 
mirable for  a  similar  purpose. 

Tenaculum    (Fig.    59).  —    ^istHSSilll 
This  is  used  to  pick  up  and 
draw    vessels     from     the    soft   FlG-  55.— Langenbeck's      Fig.  56.— Wire  serre- 

,         T»   ,,  ,  .,        j,  serrefine.  fine, 

parts.     It  the  extremity  ot  a 

vessel  be  too  short  to  be  ligatured  by  the  aid  of  forceps,  it  can  be  trans- 


Fig.  54. — Serrefine  forceps. 


Fig.  57. — Gross'  artery  compressor, 


AGENTS  FOR   CONTROLLING  HEMORRHAGE. 


35 


fixed  along  with  a  small  portion  of  the  contiguous  soft  parts  by  the 
tenaculum,  and  a  ligature  thrown  around  the  combined  tissues  (Fig. 
60).  If  a  nick  be  made 
on  either  side  of  the  tis- 
sues raised  by  the  tenac- 
ulum, the  ligature  can 
be  more  securely  applied 
and  the  vessel  more  firm- 
ly grasped. 

Prince's  tenaculum 
forceps  combine  the 
principles  of  both  in- 
struments, and  can  be 
used  with  advantage 
(Fig.  62). 

The  arterial  com- 
pressor of  Speir,  of 
Brooklyn  (Fig.  61),  is 
an  instrument  of  un- 
doubted efficacy,  but  the 
advantages  which  it  is 
said  to  possess  over  the 
ordinary  ligatures  are 
not  of  enough  impor- 
tance to  commend  it  to 
general  use.  A  small 
portion  of  the  vessel  is 
isolated  and  its  hook- 
like extremity  passed 
around  it  ;  the  handle 
is  then  turned  until  the 
coats  are  compressed  suf- 
ficiently to  divide  the 
innermost,  as  is  accom- 

pli,hed  in  the  tightening  Pl0     59.  FiG  60._Application  of  Pro. 
of  the  ordinary  ligature.    -Tenac-     tenaculumY0  vessels.         artery  comPres- 

Cautery. — This  rem- 
edy,  once   a  universal  means  of  controlling  hemorrhage,  has  now  but 

a  limited  applica- 
tion.     There  are 
three  varieties  of 
I  cautery   in   com- 

lic.  02. — Prince's  Tenaculum  forceps. 

tual,  the  thermo- 
and  galvano-cauteries.     The  actual  cautery  requires  the  cautery  irons 


36 


OPERATIVE   SURGERY. 


Fig.  63. — Cautery  irons 


(Fig.  63),  which  should  be  accompanied  by  the  blow-pipe  (Fig.  64), 
although  they  can  be  heated  by  ordinary  means.   The  blow-pipe  is  by  far 

the  best,  since  during  the 
'  summer  months,  or  in  un- 
l  favorable  situations,  when 
great  haste  is  necessary,  the 
domestic  means  of  heating 
them  will  be  inadequate. 
The  irons  can  be  made  in- 
candescent, or  of  a  dull  red 
color  ;  the  latter  is  the  bet- 
ter, since  it  burns  more 
deeply  and  is  less  liable  to 
be  followed  by  secondary 
hemorrhage. 

Tliermo-cautery. —  The 
instrument  designed  by  M. 
Paquelin  for  this  purpose 
is  exceedingly  ingenious. 
It  consists  of  a  thorough- 
ly isolated  hollow  handle, 
provided  with  three  movable  platinum  cauteries,  into  which,  after  they 
have  been  heated  in  the  flame  of  a  spirit  lamp,  a  continuous  stream 
of  benzine  vapor  is  introduced  by  the  means  of  a  double  spray  bulb 
connected  by  a  tube  with  the  bottle  containing  it  (Fig.  65) ;  this 


Fig.  64. — Blow-pipe. 


Fig.  65. — Paquelin's  thermo-cautery. 


AGENT?   FOR   CONTROLLING  HEMORRHAGE. 


37 


brings  the  cauteries  quickly  to  the  required  temperature,  which  can 
be  maintained  for  an  indefinite  length  of  time  by  squeezing  the  rubber 
bulb.  The  range  of  the  usefulness  of  this  instrument  is  more  extended 
than  the  former.  It  is  used,  not  only  for  the  same  purposes,  but  can 
be  employed  as  a  cutting  implement  for  the  removal  of  morbid 
growths,  etc.,  when  union  by  first  intention  becomes  a  lesser  consid- 
eration than  the  annoyance  from  primary  hemorrhage. 

Galvano-cautery. — This  method  is  chiefly  erupted  in  connection 
with  uterine  surgery,  although  it  is  a  proper  'expedient  in  connection 
with  all  operations  where  the  use  of  the  ecraseur  is  admissible. 

Ligatures. — The  ligature  is  by  far  the  best  general  agent  for  con- 


Fig.  66. — Tyinjr  a  ligature. 


trolling  hemorrhage.  It  can  be  readily  applied,  is  easily  portable,  and 
can  always  be  obtained  in  some  form.  Ligatures  may  be  classified 
according  to  their  nature  into  organic  and  inorganic.  The  latter  are 
very  infrequently  used,  and  then  in  the  form  of  fine  silver  or  iron 
wire,  which  is  looped  rather  than  tied  around  the  vessel.  The  organic 
comprise  the  hemp,  silk,  and  catgut  varieties,  which  should  be  made 
at  least  from  twelve  to  sixteen  inches  in  length,  depending  on  the 
depth  of  the  wound  in  which  they  are  to  be  applied.  They  must  be 
of  sufficient  strength  to  withstand  the  traction  necessary  to  cause 
complete  occlusion  of  the  vessel.  Their  size  must  depend  somewhat 
upon  the  force  to  be  employed  in  tying.  The  requisite  force  to  prop- 
erly occlude  a  vessel  can  not  be  estimated  by  ounces  or  pouuds,  but  is 
largely  a  matter  of  experience.  The  traction  should  be  made  steadily, 
and  over  the  ends  of  the  forefingers  or  thumbs,  without  disturbing 
the  relations  of  the  vessel  to  its  surrounding  parts  (Fig.  66).  The 
giving  away  of  the  inner  coat  of  a  vessel  indicates  that  the  ligature  is 
drawn  .sufficiently  tight.  This  can  not  be  felt,  however,  except  in  con- 
nection with  the  larger  vessels.  Great  caution  is  to  be  exercised  to 
prevent  any  tissues  other  than  the  walls  of  the  vessel  being  included  in 
the  grasp  of  the  ligature.  If  a  nerve  be  included  the  patient  will  he 
tormented  by  constant  pain,  which  may  not  cease  even  with  the  dis- 
appearance of  the  constricting  agent.    All  tissues,  other  than  the  coats 


ss 


OPERATIVE   .SURGEEY. 


of  the  vessel,  not  only  cause  additional  irritation,  hut  delay  the  sepa- 
ration of  the  ligature. 

Knots. — The  security  of  the  ligature  depends  yery  much  on  the 
kind  of  knot  tied.     The  surgeon's  knot  is  tied  by  making  two  turns 

of  the  ligature  at  first  instead  of  one 
(Fig.  67 j  :  it  will  not  slip  when  drawn 
tightly,  and  should  always  be  em- 
fa  o  the  knot  is  to  be  made 
.1  the  sight  of  the  surgeon, 
otherwise  the  first  half  of  it  may  slip 
without  his  knowledge,  thereby  re- 
sulting in  an  imperfect  ligaturing  of 

the  yesseL     It  sometimes  happe ring  to  the  ligature  becoming 

soaked,  that  this  knot  can  not  be  drawn  as  tightly  aa  one  with  a 


J:.  -.:- 


single  turn.     If  it  binds  in  this  manner,  the  tying  cd 
will  leaye  the  whole  yery  insecure. 

The  Reef  or  Square  Knot. — Either  this,  or  the 
always  be  employed  in  a  ~esseL  The  reef-knot 
confound  -  ]  with  th  E  '  ■'  granny  ".-:  Pig.  69),  which 

following  description  of 
the  method  of  tying  : 
reef-  kn . :.   taken  from 
Heath,  is  too  graphic  fct 
subs  dtnted    by   ;  uy 
other  :         b     I  g -.  ; 
to  be  held  in  the  palm  of 
the  right  hand  be:  u  ■  -.  n 
the  thumb  and  finger; 
the  end   is   then  to  be 
thrown    around  the  for  - 
seps  closely  and  eaaghft 
with  the  left  hand,  and  carried  across 
tween  the  third  and  fourth  finger  a  rfti 
at  the  same  moment  seizes  the  other  en 
drawn  out  as  is  being  done  in  Kg 


—I 


AGENTS  FOR   CONTROLLING  HLTJORR: 


■     -i 


ty  in  drawing  the  knot  thus  formed  tight  with  the  forefingers,  or,  if 
preferred,  with  the  thumbs  (Fig.  72).  To  complete  the  knot  by  mak- 
ing another  tie,  the  same 
manoeuvre  is  to  be  effected, 
taking  care  always  to  begin 
with  the  opposite  hand  to 
that  which  began  befo: 
is  quite  immaterial  which 
hand  begins  the  first  part  of 
the  knot,  so  long  as  the  op- 
posite one  always  begins  the 
second  part ;  in  this  way, 
with  a  little  practice,  the 
reef-knot  may  be  unerringly 
tied  with  the  greatest  rapid- 

When    the    knc- 
completed,  it  will  be   seen 

that  the  ends  of  the  ligatures  lie  parallel  with  and  in  contact  with  the 
portion  of  the  ligature  which  surrounds  the  vessel  (Fig.  68). 

The  silk  and  hemp  ligatures  must  be  well  puri- 
fied before  they  are  applied  by  being  placed  in  a 
suitable  disinfecting  solution-  A  solution  of  bi- 
chloride of  mercury  (1-1,500),  or  the  -  lu- 
tion  of  carbolic  acid,  may  be  employed,  although 
the  latter  diminishes  the  strength  of  the  ligatur 

impairing  the  integrity  of 
its  fiber.  If  the  ligatures 
be  wound  on  small  glass 
bobbins  and  placed  in  suit- 
ably sized  large-mouthed 
bottles  containing  the  anti- 
:■  fluid  for  a  week  or 
ten  days,  then  transferred 
milar  bottles  contain- 
ing absolute  alcohol,  their 
ends  escaping  through  a 
narrow  groove  in  the  side  of  the  cork,  they  can  be  unwound  as  re- 
quired without  exposing  the  remaining  portions  to  external  influ- 
M.  If  uncarbolized,  they  should  be  freshly  waxed.  After  tying, 
one  end  may  be  cut  short  and  the  other  allowed  to  hang  from  the 
wound. 

iron-dyed  silk  ligature  recommended  by  Pancoast  is  credited 
me  with  the  attributes  of  the  aseptic  o: 
_ut  ligatures  are  now  in  established  use  in  surgery ;  they,  like 
other  ligatures,  vary  in  size  and  strength,  and  a  selection  must  be 


F:c  71— T:.i:  I 


40  OPERATIVE  SURGERY. 

made  in  accordance  with  the  purposes  in  view.  If  properly  chosen 
they  can  be  relied  upon  to  fulfill  the  ordinary  indications  of  the  silk 
ligature.  Crude  catgut  of  assorted  sizes  can  be  purchased  of  dealers 
in  surgical  supplies  and  be  asepticized  to  suit  the  fancy  of  the  surgeon, 
or  it  may  be  procured  already  prepared  for  use  after  the  methods  in 
common  practice.  Catgut  can  be  tied  by  the  surgeon's  or  the  reef- 
knot,  but  is  less  secure  than  silk.  A  third  tie  should  always  be 
added  to  whichever  of  the  two  is  employed.  The  ends  are  cut  close 
to  the  point  of  tying,  and  the  wound  closed  irrespective  of  the  pres- 
ence of  the  ligature.  Aseptic  kangaroo  tendon,  silkworm  gut,  aortic 
tissue,  whalebone  tissue,  etc.,  are  also  commended  for  special  purposes, 
but  they  possess  a  greater  novelty  than  practical  utility. 

The  crude  material  is  variously  prepared  to  conform  to  the  de- 
mands of  asepsis,  ready  absorption,  and  non-irritation.  It  can  be 
placed  in  a  bichloride  solution — 1  to  100  of  water — for  ten  minutes, 
then  into  a  weaker  one — 1  to  1,000 — for  twelve  or  fourteen  hours,  and 
afterward  wound  on  bobbins  and  kept  for  ready  use  in  absolute  alcohol 
in  the  manner  before  described  ;  or  it  may  be  prepared  after  the 
method  of  Kocher,  of  Berne,  by  first  putting  it  into  the  oil  of  juniper 
for  twenty-four  hours,  and  afterward  into  absolute  alcohol.  Ligatures 
prepared  by  these  methods  meet  all  of  the  indications  admirably,  and 
are  devoid  of  the  slipping  tendencies  of  those  kept  in  acid  and  oil 
after  the  manner  of  Mr.  Lister.  The  following  method  of  preparing 
ligatures  was  recommended  by  Lister,  in  his  inaugural  address  of  June 
28,  1881  : 

"Dissolve  one  part  of  chromic  acid  in  4,000  parts  of  distilled 
water,  and  add  to  the  solution  200  parts  of  pure  carbolic  acid ;  into 
this  liquid  immediately  put  catgut  equal  in  weight  to  the  carbolic  acid. 
At  the  end  of  forty-eight  hours  it  is  sufficiently  prepared.  Then  it  is 
to  be  removed  from  the  solution,  dried,  and  placed  in  one-to-five  car- 
bolized  oil.  It  is  then  fit  for  use."  The  dry  chromacized  catgut  is  not 
satisfactory,  owing  to  its  hardness  and  power  of  resisting  absorption. 

Assistants. — The  number  of  efficient  assistants  necessary  to  con- 
duct an  operation  with  ease  is  modified  by  its  character. 

To  one  must  be  intrusted  the  administering  of  the  anaesthetic,  and 
watching  the  pulse,  respiration,  and  circulation  of  the  patient.  By  com- 
bining these  duties  the  administrator  of  the  anaesthetic  becomes  the  im- 
mediate observer  of  its  effects,  and  he  must  always  be  prepared  to  carry 
into  execution  the  various  expedients  that  are  recommended  in  the  com- 
plications attending  anaesthesia.  If  the  temporal  and  radial  pulsations 
be  compared  before  its  administration,  the  assistant  will  be  able  to 
judge  of  one  from  the  character  of  the  other.  He  can  then  give  the 
anaesthetic,  hold  forward  the  lower  jaw  to  prevent  swallowing  the 
tongue  (Fig.  10),  and,  with  the  finger  on  the  temporal  artery,  he  will  be 
able  to  attend  to  the  necessities  of  the  case  without  any  interruption. 


TREATMENT   OF  OPERATIOX-WOUNDS.  41 

To  a  second  should  be  assigned  the  care  of  the  instruments  ;  hand- 
ing them  to  the  surgeon  when  asked  for,  and  returning  them  to  a 
place  of  safety  after  being  used. 

To  a  th  ird  may  be  intrusted  the  care  of  the  sponges ;  he  must 
always  see  to  it  that  a  suitable  number  be  well  squeezed  and  placed  at 
the  convenience  of  the  operator. 

To  a  fourth  the  ligatures  should  be  given.  He  can  first  hold  the 
limb,  when  necessary,  after  which  he  may  either  sponge  or  ligature 
the  vessels,  as  best  suits  the  circumstances  of  the  case  or  the  fancy  of 
the  operator.  The  securing  of  the  bleeding  points  and  the  necessary 
sponging  are  best  done  by  the  operating  surgeon  ;  however,  these  are 
matters  which  will  become  self-regulating  as  the  operation  progresses. 
All  assistants  must  be  proficient,  especially  the  one  who  ligatures  the 
vessel,  and  the  one  who  administers  the  anaesthetic.  When  the  sur- 
geon is  not  able  to  avail  himself  of  a  suitable  number  of  assistants,  he 
must  then  draw  upon  his  own  resources.  This  can  be  done  by  placing 
the  sponges  and  instruments  where  they  can  be  conveniently  reached, 
when  he  can  sponge,  secure,  and  tie  the  vessels.  If  the  circumstances 
demand  it,  he  can  at  the  same  time  control  the  administration  of  the 
anaesthetic.  If  the  operation  is  to  be  antiseptic,  the  entire  charge  of 
the  douching  should  be  given  to  one  assistant. 

The  patient  should  always  be  prepared  for  the  operation.  The 
physical,  legal,  and  spiritual  aspects  of  a  preparation  have  been  here- 
tofore considered  under  various  headings,  consequently  little  remains 
to  be  advised  other  than  to  properly  cleanse  and  shave  the  part  to  be 
operated  upon. 


CHAPTER  III. 
TREATMENT  OF  OPERATION-WOUNDS. 

It  is  absolutely  necessary  to  have  the  proper  materials  for  uniting 
and  dressing  wounds,  together  with  a  knowledge  of  their  tise. 

As  soon  as  the  operation  is  completed  the  wound  should  be  washed 
thoroughly  with  the  strong  solution  of  carbolic  acid,  or  other  anti- 
septic, which  not  only  purifies  it,  but  serves  to  check  the  capillary 
oozing  of  the  incised  surfaces.  The  proper  securing  of  the  incised  sur- 
faces and  the  dressing  of  the  wound  involve  three  important  considera- 
tions :  1,  the  retentive  coaptation  of  the  divided  tissues ;  2,  perfect 
drainage  ;  3,  the  application  of  some  suitable  protective  dressing.  If 
union  by  first  intention  be  a  desideratum,  the  incised  surfaces  must  be 
kept  in  perfect  coaptation.  For  this  purpose  there  are  numerous 
means  employed.     The  part  bearing  the  wound  should  be  so  placed  as 


42 


OPERATIVE   SURGERY. 


to  avoid  all  muscular  contraction,  or  undue  tension  of  the  soft  parts. 
Strips  of  adhesive  plaster  with  or  without  roller  bandages,  or  simple 
compresses  may  meet  the  indications.  These  agents  constitute  the 
common  dressings  of  a  less  recent  date,  and  are  at  the  present  time 
open  to  the  objection  of  interfering  with  union  by  first  intention,  ex- 
cept they  be  of  an  antiseptic  nature. 

Sutures  may  be  classified  with  reference  to  their  composition  or 
method  of  arrangement.    They  are  of  either  organic  or  inorganic  nature. 

Those  of  an  organic  nature  are  most  commonly  used ;  but  which 
of  these  is  the  best  is  more  a  matter  of  personal  preference  than  a 
surgical  requirement.  The  silk,  hemp,  catgut,  and  horse-hair  sutures 
belong  to  this  class,  and  are  respectively  employed  as  best  suits  the 
preference  of  the  surgeon.  The  silk  and  the  hemp  varieties  are  con- 
stantly employed,  and  if  carbolized  they  cause  but  little  irritation, 
may  become  absorbed,  and,  when  present,  can  be  removed  without  pain. 

The  proper  introduction  of  sutures  under  all  conditions  requires 
needles  of  various  shapes  and  sizes  :  the  curved  and  straight ;  those 
with  round  and  edged  extremities.  These  are  too  familiar  to  all  to 
require  other  than  a  passing  mention.  The  curved  are  used  in  cavi- 
ties and  depressions  ;  the  straight  on  plane  surfaces.  Those  with  an 
edged  extremity  cut  the  tissues  they  pass  through,  while  the  smoother 
separate  the  tissues  and  avoid  the  hemorrhage  that  so  often  follows 
the  track  of  the  former.  The  latter  are,  however,  inserted  with 
greater  difficulty. 

Needle  forceps,  or  holders  (Figs.  73,  74,  75),  should  always  be  at 


Fig.  74. — Prout's  needle  forceps. 


Fig.  15. — Sands'  needle  forceps. 


TREATMENT   OF   OPERATION-WOUNDS. 


43 


hand  to  aid  in  conducting  the  needles  steadily  through  the  tissues. 
The  instrument  bearing  the  artery  forceps  at  one  end  and  the  needle- 
holder  at  the  other  (Fig.  76)  is  an  admirable  and  compact  implement. 


Fig.  76. — Combined  forceps  and  needle-holder. 


Horse-hair. — When  carbolized,  this  causes  but  slight  irritation, 
and  is  well  adapted  to  those  cases  requiring  but  little  force  to  maintain 
coaptation  and  where  scarring  from  sutures  is  to  be  avoided. 

Catgut  as  a  suture  possesses  the  same  special  advantages  that  be- 
long to  it  as  a  ligature.  It  rarely  produces  irritation,  and  if  allowed 
to  remain  will  become  absorbed  without  ulceration.  If,  however, 
much  force  is  required  to  unite  the  wound,  catgut  is  less  reliable  than 
silk. 

Inorganic  or  Metallic  Sutures. — Those  in  common  use  are  the 
silver  and  iron  wire.  They  can  be  retained  in  situ  longer  than  the 
uncarbolized  silk  or  hemp,  with  less  danger  from  ulceration.  Their 
application  and  removal,  however,  are  attended  with  more  pain  than 
either  of  the  others.  The  silver  wire  is  more  expensive  than  the  iron  ; 
aside  from  this,  it  matters  little  which  be  used.  The  depth  to  which 
sutures  should  be  passed,  the  distance  between  them,  and  their  ten- 
sion, depend  upon  the  depth  of  the  wound,  and  the  tendency  of  its 
lips  to  separate.  The  object  of  all  sutures  is  to  hold  the  surfaces  of 
wounds  in  close  contact  until  union  occurs.  To  accomplish  this  they 
must  be  carried  to  such  depth,  and  be 
placed  at  such  distances  from  each  other, 
as  will  best  accomplish  the  purpose. 
They  can,  if  necessary,  be  supplemented 
by  strips  of  adhesive  plaster  passed  be- 
tween them  that  have  been  heated  by 
immersion  in  a  hot  solution  of  bichloride 
of  mercury  (1-500)  (Fig.  77).  Sutures 
must  never  be  drawn  too  tightly  (Fig. 
79),  or  the  tissues  within  their  grasp  will 
be  strangulated,  causing  ulceration  and 
disfigurement. 

If  the  integument  within  the  grasp 
of  a  suture  remain  white  after  it  is  tightened,  the  suture  must  bo 
loosened  before  the  final  dressing  is  completed.     The  length  of  time 
sutures  should  remain  is   to  be  governed  by  the   danger  of  ulcera- 


Fig.  77. — Antiseptic  adhesive  plas- 
ter between  sutures. 


u 


OPERATIVE   SURGERY. 


tion  and  disfigurement,  also  the  tendency  of  the  wound  to  open. 
In  exposed  portions  of  the  body,  they  should  be  removed  as  soon 
as  notable  irritation  is  observed.  The  rapidity  and  extent  of  the 
ulcerative  process  can  be  lessened,  by  relieving  any  undue  traction 
upon  them,  by  strips  of  adhesive  plaster  or  by  other  supporting 
means. 

Different  Forms  of  Sutures. — The  interrupted,  continuous,  quilled, 
hare-lip,  etc.,  are  the  forms  in  common  use.     The  special  varieties  for 
intestinal  sewing  will  be  shown  in  connection 
with  operations  upon  the  intestines. 

The  interrupted  suture  is  the  one  in  every- 
day use,  and  has  a  more  general  application  than 
the  other  forms  (Fig. 
78).  It  is  made  by 
passing  a  needle  armed  with  a  well-pre- 
pared suture  through  the  integument, 
from  a  line  to  a  third  of  an  inch  or  more 
from  the  borders  of  the  wound,  depend- 
ing upon  its  size,  depth,  and  retractive 
force.  The  ends  are  then  united  by  a 
reef-knot,  drawn  with  sufficient  force  to 
oppose  the  surfaces  without  puckering  the 
skin  (Fig.  79).  The  ends  of  the  suture 
can  be  united  at  alternate  sides  of  the 
wound,  or  at  one  of  its  points  of  exit  alone. 


-Interrupted  su- 
ture. 


How  to  do  it. 


,.(f^v[  How  not  to  do  it. 
Fig.  79. — Tension  of  sutures. 


Fig.  80.- 


-Continuous,  or  glover's 
suture. 


The  latter  is  the  better,  since,  if  the  dress- 
ings cling  to  the  extremities,  their  remov- 
al is  less  liable  to  interfere  with  the  line 
of  coaptation. 

The  continuous  suture,  sometimes 
called  the  glover's  suture  (Fig.  80),  is  used 
to  unite  superficial  wounds,  and  such  oth- 
ers as  require  little  force  to  secure  a 
proper  adjustment  of   the   divided  sur- 


Fig.  81. — Quilled  suture. 


TREATMENT   OF   OPERATIOX-WOUNDS. 


45 


faces.     This  is  made  by  passing  the  needle  diagonally  from  one  side  of 
the  wound  over  to  the  other. 

Tlie  Quilled  Suture. — This  is  made  by  passing  several  strong  double 
threads  through  the  lips  of  the  wound,  half  an  inch 
or  so  apart,  and  tying  them  over  quills,  wood,  etc., 
while  they  lie  parallel  with  the  cut  (Fig.  81).  It  is 
used  about  the  vagina,  perineum,  etc.,  when  deep 
gaps  are  to  be  closed. 

The  Twisted  or  Hare-lip  Suture  (Figs.  82  and 
83). — This  is  made  by  pushing  a  pin  through  the 
edges  of  the  wound,  and  passing  cotton  yarn  around 
it  to  confine  it  in  position  (Fig.  83).  The  yarn 
should  be  changed  as  often  as  it  becomes  soiled.  If 
it  be  properly  carbolized  before  application,  it  lessens 
its  tendency  to  cause  irritation.  An  ordinary  pin  or 
needle  can  be  used,  although  those  specially  adapted  FlG 
for  the  purpose  are  preferable  (Fig.  84).  They  can 
be,  if  not  spear-pointed,  pushed  or  drawn  through  the  tissues  by  aid 
of  Post's  (Fig.  85)  or  Buck's  pin-carrier,  after  which  the  points  should 
be  nipped  off  and  separated  from  the  skin  by  a  small  strip  of  adhesive 


82.— Hare-lip 
suture. 


Fig.  83. — Hare-lip  suture. 


46 


OPERATIVE   SURGERY. 


Fig.  84. 


plaster.     Pins  with  adjustable  spear-shaped  points  can  be  employed 
and  carried  into  position  by  the  fingers  of  the  operator  (Fig.  86). 

There  are  various  other  special  forms 
/  of  sutures  which  will  be  considered  under 

/  their  proper  headings. 

Drainage. — This  is  not  only  of  the 
greatest  importance  in  securing  successful 
union  of  the  divided  surfaces,  but  also  to 
the  safety  of  the  patient.  Good  drainage 
to  a  wound  is  as  potent  to  its  cleanliness,  as 
is  the  good  drainage  of  a  dwelling  to  the 
healthfulness  of  its  occupants.  No  one  lo- 
cal condition  will  interfere  so  materially 
with  the  process  of  healing,  or  expose  the 
patient  to-  greater  constitutional  danger, 
than  the  collection  and  decomposition  of 
fluids  in  a  wound.  Drainage  may  be  se- 
cured through  dependent  incisions,  or,  bet- 
ter still,  by  the  introduction  into  the  wound 
of  a  drainage-tube.  Horse-hairs  or  threads 
introduced  into  the  wound  in  some  cases 
Fig.  85.    Fig.  86.  answer  quite  well.     The  long  extremities 

Fig.  84.—Hare-lip  pins    Fig.  85.   0f  t^e  sjik  or  linen  ligatures,  if  allowed  to 
— Post's  pin-carrier.   Fig.  86. —         .       .    „  . .  °  .  ,      , 

Adjustable  pointed  pin.  extend  from  its  most  dependent  portion, 

will  drain  it,  though  somewhat  imperfectly. 
Ellis'  Drainage  Spiral  (Fig.  87),  or  that  which  is  still  more  practi- 
cable, the  rubber  drainage-tube  (Fig.  88),  will  fulfill  the  indications  more 
perfectly.  An  ordinary  piece  of  black  or  white  rubber  tubing,  of  about 
one  fourth  of  an  inch  in  diameter,  with 
holes  in  the  sides  at  irregular  intervals, 
can  be  inserted  into  the  bottom  of  the 
wound  cavity  through  its  most  depend- 
ent portion.  Another  can  be  introduced  into  the  upper  portion  of  the 
cavity  through  the  uppermost  angle  of  the  wound.     The  size  should 

vary  with  the  dimen- 
sions of  the  wound. 
They  are  more  often 
too  small  than  too 
large.  They  must 
be  fastened  in  posi- 
tion, or  they  may  slip  into  the  wound  ;  this  can  be  done  by  passing  a 
thread  through  the  projecting  extremity  and  tying  it  around  the  limb. 
If  a  single  tube  be  passed  so  as  to  protrude  from  both  sides  of  the 
wound,  it  can  be  securely  fastened  by  passing  an  ordinary  safety  pin 
through  each  extremity.     However,  it  is  better  to  use  two  short  tubes 


Fig.  87. — Ellis'  drainage  spiral. 


Fig.  88. — Rubber  drainage  tube. 


TREATMENT   OF  OPERATIOX-WOUNDS.  47 

than  one  long  one  ;  the  use  of  the  latter  introduces  into  the  wound  a 
superfluous  amount  of  rubber,  which  does  not  perform  a  duty  com- 
mensurate with  its  presence.  In  either  case  it  is  necessary  to  allow  for 
the  swelling  of  the  parts,  else  the  pins  or  threads  may  cause  constric- 
tion of  the  injured  tissues.  The  outer  extremities  should  then  be  cut 
off  flush  with  the  soft  tissues.  The  wound  can  be  washed  though  the 
upper  tube, while  all  discharges  will  pass  from  the  lower  one.  The  length 
of  time  they  should  remain  must  dejDend  upon  the  character  and  amount 
of  the  discharge.  When  the  amount  is  small  and  of  inoffensive  nature, 
they  can  be  removed.  It  must  not  be  forgotten  that  the  tubes,  as  foreign 
bodies,  may  excite  the  discharge  which  they  are  introduced  to  carry  off. 

Tlie  decalcified  tubes  of  Neuber  are  admirable,  although  not  suffi- 
ciently accessible  to  supplant  the  rubber  ones ;  moreover,  they  not 
infrequently  become  absorbed  before  the  wound  is  sufficiently  healed 
to  properly  dispense  with  their  use.  Several  strands  of  the  ordinary 
antiseptic  catgut  can  be  introduced  together  and  retained  in  the 
wound  ;  they  drain  satisfactorily,  and  are  easily  absorbed.  Chicken- 
bones,  decalcified  by  a  weak  solution  of  hydrochloric  acid,  may  be  ex- 
temporized, and,  while  they  are  suitable  substitutes  for  the  rubber 
tubes,  they  are  too  hard  to  be  absorbed,  and  consequently  do  not  add 
materially  to  the  surgeon's  equipment.  A  drainage-tube  can  be  pushed 
into  position  often,  although  it  is  better  if  it  be  aided  by  a  director  or 
probe  inserted  within  it,  either  as  a  propelling  agent  or  a  guide.  It 
may  be  pushed  or  drawn  into  place  by  the  ordinary  thumb-forceps  ; 
the  latter  is  the  better  if  the  wound  be  open. 

Canalization. — This  term  is  applied  by  Neuber  to  a  method  of 
establishing  good  drainage  to  a  wound  without  the  use  of  tubes.  Shal- 
low and  deep  canalization  comprise  its  varieties.  The  former  is  the 
draining  of  shallow  subcutaneous  cavities  by  oval-shaped  punctures  a 
fourth  of  an  inch  or  so  in  width  through  the  integumentary  laps  at 
the  most  dependent  portion  of  the  wound.  These  punctures  vary  in 
number  and  situation  to  meet  the  demands  of  the  case,  and  are  made 
by  a  punch,  in  construction  not  unlike  the  leather-punch  ;  in  fact,  the 
latter  may  bo  employed  as  a  suitable  substitute.  Deep  canalization  is 
directed  to  the  drainage  of  deep  wound  cavities,  such  as  are  formed 
by  the  removal  of  the  female  breast,  of  the  connective  tissue  from  the 
axilla,  and  other  deep  wounds,  which,  when  united  by  granulation, 
produce  an  objectionable  amount  of  cicatricial  tissue.  The  integu- 
ment at  either  border  of  the  wound  is  loosened  from  its  deep  connec- 
tions to  an  extent  sufficient  to  permit  its  borders  to  be  easily  drawn 
or  slid  into  apposition  with  each  other  and  carried  to  the  bottom  of 
the  wound  cavity,  to  which  they  are  connected  by  sutures.  The  sur- 
face then  appears  concave  or  trough-like,  and  is  covered  by  the  de- 
pressed integument,  which  it  is  intended  shall  become  united  to  the 
wall.-;  and  floor  of  the  cavity  by  first  intention. 


48 


OPERATIVE  SURGERY. 


Protective  Dressings. — These  include  the  ordinary  dressings,  such 
as  one  who  is  a  long  way  from  the  base  of  supplies,  or  not  a  believer  in 
the  modern  methods,  would  employ  :  as  covering  the  wound  with  a 
linen  cloth  kept  moist  with  a  weak  solution  of  carbolic  acid,  or  water  ; 
the  application  of  adhesive  plaster,  and  covering  it  with  medicated 
cloths  held  in  position  by  bandages  or  plasters.  Of  the  modern  meth- 
ods, the  one  bearing  the  name  of  Lister,  its  designer,  is  deserving  of 
especial  mention,  not  only  on  account  of  its  acknowledged  worth,  but 
also  from  the  fact,  that  other  measures  involving  similar  principles 
are  advocated,  the  same  result  being  sought  by  the  aid  of  different 
agents. 

The  requirements  for  the  Lister  treatment  are  the  atomizer  or 
spray,  carbolic -acid  solution,  drainage-tube,  protective,  antiseptic 
gauze,  Mackintosh,  antiseptic  catgut  ligatures,  and  that  everything  to 
be  brought  in  contact  with  the  wound  be  made  aseptic  by  a  strong 
solution  of  carbolic  acid  or  other  proper  fluid. 

The  Antiseptic  Spray  Apparatus  consists  of  a  kettle,  lamp,  spray- 
tube,  and  a  bottle  to  contain  the  solution  of  a  strong  carbolic  acid 
(Fig.  89).  The  spray  is  produced  and  directed  upon  the  site  of  the 
operation  before  the  first  incision  is  made.     It  should  be  continued 


Fig.  89. — Weir's  spray  apparatus. 

through  the  whole  operation,  and  until  the  wound  is  surrounded  by 
the  protective  dressing.  It  is  always  to  be  used  when  the  wound  is 
redressed. 

The  Protective,  which  somewhat  resembles  oiled-silk,  is  placed  over 
the  wound  and  extended  an  inch  or  so  from  its  border,  with  openings 
through  it  for  the  mouths  of  the  drainage-tubes.  A  small  piece  of  the 
antiseptic  gauze  wet  in  the  strong  solution  of  carbolic  acid  can  be  laid 
over  and  beyond  the  protective.  Numerous  layers — eight  or  ten— of 
the  antiseptic  gauze  are  then  made  to  cover  the  part,  their  borders 
extending  a  good  distance  beyond  the  edge  of  the  wound.     Around 


TREATMENT   OF   OPERATION-WOUNDS.  49 

the  whole  is  wrapped  the  Mackintosh,  which  is  confined  in  position  by 
bandages  made  of  the  antiseptic  gauze.  ( 

This  dressing  can  be  removed  on  the  second  or  third  day,  the 
wound  washed  out,  protective  and  Mackintosh  purified,  and  clean 
gauze  substituted,  after  which  it  need  not  be  examined  again — other 
things  being  equal — within  a  week  or  ten  days,  unless  the  discharges 
soak  through  it. 

At  the  present  time  the  spray  is  less  often  employed  than  for- 
merly. In  place  of  it,  the  surface  to  be  operated  upon  should  be 
thoroughly  scrubbed  for  three  minutes  with  a  brush  and  soap  and 
water,  and  afterward  washed  with  a  strong  solution  (1-20)  of  carbolic 
acid  (Kummell)  and  some  other  suitable  disinfectant,  as  aq.  chlorinii 
or  a  solution  of  thymol,  and  the  surfaces  contiguous  to  it  should  be 
covered  by  towels  saturated  with  the  same  disinfecting  solution,  which 
should  be  kept  thoroughly  wet  by  it  during  the  operation.  The  opera- 
tion-wound should  be  likewise  thoroughly  douched  with  some  disin- 
fecting fluid  during  the  entire  course  of  the  procedure.  In  all  other 
respects,  however,  the  details  are  substantially  similar  to  the  preceding. 

The  Douching  apparatus  is  easily  made  by  siphoning  the  anti- 
septic solution  from  a  receptacle  through  a  long,  small  rubber  tube,  to 
the  end  of  which  is  attached  a  metallic  one  that  discharges  the  fluid 
upon  the  wound  through  a  number  of  coarse  openings  at  its  extremity. 
The  flow  can  be  regulated  by  pinching  the  tube,  or  by  the  attachment 
of  a  regulator  constructed  to  meet  the  indication. 

The  part  to  be  operated  upon  should  be  isolated  by  means  of  rub- 
ber cloths,  to  prevent  the  patient's  clothing  becoming  saturated  by 
the  antiseptic  fluid,  and  by  towels  saturated  by  strong  antiseptic  solu- 
tions. If  the  operating  table  be  tilted  sidewise  it  will  facilitate  the 
escape  of  the  fluid  upon  the  floor,  or  into  receptacles  provided  for  the 
purpose. 

Cotton-batting  Dressing. — Cotton  batting,  or  that  which  is  better, 
borated,  or  salicylated  cotton,  is  frequently  employed  as  a  protective 
dressing  in  place  of  the  antiseptic  gauze.  The  results  obtained,  war- 
rant the  belief  that  it  is  entitled  to  be  considered  worthy  of  an  ex- 
tended application.  It  exerts  a  very  desirable  uniform  pressure  upon 
the  parts  to  which  it  is  applied,  thereby  aiding  coaptation  and  foster- 
ing union. 

Combined  Dressing. — Combined  dressing  is  made  by  placing  sev- 
eral thicknesses  of  borated  or  other  variety  of  antiseptic  batting  be- 
tween two  layers  of  antiseptic  gauze.  This  is  shaped  to  suit  the 
circumstances  of  the  case  and  applied  over  the  gauze  that  is  placed  in 
immediate  contact  with  the  wound  and  confined  in  position  by  anti- 
septic bandages  (Pig.  90). 

Iodoform  Dressing. — [odoform  can  be  dissolved  in  ether,  and  after 
the  operation  thrown  upon  the  incised  surface  by  means  of  an  ordinary 
4 


50 


OPERATIVE   SURGERY. 


atomizer.      The  ether  will  evaporate  and  leave  the  iodoform  evenly- 
deposited  over  the  incised  surfaces. 

It  can  be  better  applied,  if  pulverized,  and  blown  into  the  wound 
by  an  insufflator.     The  wound  is  then  closed  by  antiseptic  sutures, 


Fig.  90. — Antiseptic  dressings  in  position. 


drainage-tubes  introduced,  iodoform  sprinkled  upon  the  integument 
in  the  vicinity  of  the  wound,  and  the  other  antiseptic  dressings  ap- 
plied, which  are  bandaged  in  place  and  allowed  to  remain  until  they 
become  soiled,  when  the  wound  is  redressed  as  before.  It  is  a  common 
practice  to  sprinkle  pulverized  iodoform  upon  the  immediate  and  con- 
tiguous surface  of  parts  operated  on,  after  the  closure  of  the  wound, 
as  soon  as  the  douche  is  stopped.  The  dressings  are  then  applied  as* 
before. 

The  odor  of  iodoform,  and  its  occasional  deleterious  effects  upon 
the  nervous  system  of  the  patient,  should  make  its  free  use  upon  large 
surfaces  infrequent  and  cautious,  especially  if  the  wound  be  one  of  the 
scalp.  * 

Iodoform  gauze  is  made  use  of  in  many  instances.  It  can  be  made 
extemporaneously,  by  rubbing  iodoform  into  sterilized  gauze,  or  by 
saturating  sterilized  gauze  with  an  ethereal  solution  of  iodoform.  This 
variety  of  gauze  seems,  at  the  present  time,  to  be  indispensable  in  the 
treatment  of  deep  wounds  associated  with  the  rectum,  vagina,  etc. 

Peat  Dressing. — Into  a  small  carbolized  gauze  bag  light  peat  or 
turf  is  introduced,  combined  with  2£  per  cent  of  iodoform  ;  over  this 
a  large  bag  filled  with  carbolized  peat  is  applied,  and  the  whole  band- 
aged firmly  in  position.  The  fine  peat  serves  admirably  to  make 
equable  pressure  and  absorb  the  discharges,  and  need  not  be  re-applied 
until  it  has  become  soiled. 

Coarse  and  fine  jute,  wood-wool,  wood-pulp,  moss,  peat,  saw-dust, 
etc.,  can  each  be  made  antiseptic  if  it  be  steeped  six  or  eight  hours  in 
a  solution  of  bichloride  of  mercury  (1-1,000),  with  5  per  cent  Of  glycer- 
in, then  wrung  out  and  allowed  to  dry,  when  suitably  sized  pads  or 
bags  can  be  made,  one  inch  or  two  thick,  by  aid  of  some  variety  of 
antiseptic  gauze. 


TREATMENT   OF   OPERATION-WOUNDS.  51 

Gauze  arid  cotton  batting  can  each  be  made  antiseptic,  after  the 
removal  of  the  oily  matters  contained  in  their  texture,  if  they  be 
placed  into  a  solution  of  bichloride  of  mercury  10  parts,  water  2,240 
parts,  glycerin  250  parts,  and  allowed  to  stand  for  ten  or  twelve 
hours,  then  wrung  out  and  dried. 

It  should  not  be  forgotten  that  the  bichloride  of  mercury  is  thought 
to  be  a  somewhat  uustable  component,  and  it  therefore  becomes  neces- 
sary to  use  the  freshly  prepared  combinations  of  it.  If  a  small  amount 
of  common  salt  be  added  to  the  solution,  its  stability  is  said  to  be 
better  maintained. 

Bichloride  of  Mercury  Dressing. — By  this  method,  the  dangers 
attending  the  use  of  carbolic  acid  and  iodoform  are  avoided,  at  the 
same  time,  a  cheap  and  inoffensive  substance  is  utilized.  It  is  used 
with  the  spray  (1-1,200)  or  as  a  wash  for  a  wound  (1-2,000-10,000). 
Sponges,  ligatures,  and  sutures  are  soaked  in  solutions  of  it,  varying 
in  strength  from  10  to  75  grains  to  the  pint  of  water  or  alcohol,  the 
latter  being  used  for  the  ligatures  and  sutures,  in  which  they  are  kept 
for  three  or  four  hours,  thence  removed  to  a  much  weaker  one.  Cat- 
gut can  be  treated  in  substantially  the  same  manner,  by  allowing  it  to 
remain  ten  or  twelve  hours  in  the  alcoholic  solution,  from  which  it  is 
to  be  taken  and  introduced  into  a  weaker  one  (one  half  of  1  per  cent), 
containing  a  drachm  or  so  of  glycerin. 

The  protective  dressing  can  be  saturated  with  a  strong  solution 
(50  grains  to  the  pint),  and  applied  in  the  same  manner  as  before.  It 
is  well  to  remember  that  if  this  variety  of  protective  be  applied 
directly  to  the  skin,  especially  of  a  child,  it  is  very  liable  to  cause  an 
erythematous  irritation. 

Instruments  can  be  purified  with  it,  although  it  lessens  their  cut- 
ting power.  This  dressing  is  recommended  as  one  possessing  efficiency 
and  safety.  The  soluble  compressed  tablets  containing  a  definite 
amount  of  bichloride  of  mercury  are  very  convenient  for  the  minor 
requirements  of  general  practice.  They  should  not,  however,  become 
in  any  way  associated  with  the  compressed  tablets  employed  for  inter- 
nal medication,  for  obvious  reasons. 

Thiersch's  Fluid,  composed  of  one  grain  of  salicylic  acid  and  six 
of  boracic  acid  to  an  ounce  of  water,  is  a  good  antiseptic  solution.  It 
does  not  produce  the  catheretic  influence  upon  the  tissues,  so  charac- 
teristic of  the  strong  carbolic  and  bichloride  of  mercury  solutions,  and 
therefore  the  tissues  to  which  it  is  applied  retain  their  normal  appear- 
ance. 

Alcohol,  thymol,  eucalyptol,  and  the  essential  oils  have  been  recom- 
mended for  their  antiseptic  virtues,  but  with  insufficient  testimony  to 
warrant  their  employment  in  place  of  the  other  well-established 
agents. 

The  Patient  should  be  kept  Quiet. — Absolute  quiet  of  the  patient, 


52  OPERATIVE   SURGERY. 

and  of  the  part  bearing  the  wound,  is  not  the  least  of  the  elements 
necessary  to  secure  a  satisfactory  result.  A  careful  record  of  the  pulse, 
temperature,  and  respiration  should  be  kept.  If  the  temperature 
rises  to  102°  F.,  and  remains  thus  longer  than  two  or  three  days,  the 
dressing  should  be  removed,  the  drainage  carefully  examined,  and  the 
parts  inspected,  after  which,  if  no  contra-indications  exist,  it  is  again 
dressed  as  before.  The  same  antiseptic  precautions  should  be  employed 
with  the  redressing  of  the  wound  as  with  the  operative  procedure  it- 
self. 

The  Common  Preparations  for  an  Antiseptic  Operation. — Operat- 
ing-Table.— The  table  should  be  well  covered  with  blankets  and  by  a 
rubber  cloth,  so  arranged  that  if  the  table  be  slightly  tilted  all  the 
fluids  employed  will  be  quickly  discharged  into  a  suitable-sized  recep- 
tacle placed  on  the  floor. 

The  Patient. — All  portions  of  the  body  not  to  be  operated  upon 
should  be  carefully  excluded  from  draughts  of  air,  and  also  from  con- 
tact with  antiseptic  fluids,  by  wrapping  them  around  and  isolating 
them  from  the  immediate  field  of  operation  by  suitably  arranged  rub- 
ber cloths. 

The  parts  to  be  operated  upon,  together  with  their  contiguous 
surroundings,  must  be  made  entirely  aseptic  by  shaving,  and  by  scrub- 
bing them  with  a  stiff  brush  and  soap  and  water,  after  which  they 
should  be  rinsed  in  the  strong  solution  of  carbolic  acid  or  chlorine 
water,  and  wrapped  in  towels  saturated  by  a  strong  antiseptic  fluid.  A 
saturated  ethereal  solution  of  iodoform  may  be  poured  over  the  imme- 
diate site  of  the  operation,  and  the  antiseptic  wraps  omitted  if  the  op- 
eration is  to  be  commenced  in  a  few  moments. 

The  surroundings,  for  a  foot  or  two  outside  the  immediate  field  of 
the  operation,  should  be  isolated  from  it  by  towels,  saturated  by  strong 
antiseptic  fluid,  with  which  they  are  kept  thoroughly  wet,  and,  when 
soiled,  they  should  be  replaced  by  clean  ones. 

The  forearms,  hands,  and  nails  of  the  operator,  and  of  others  who 
are  brought  in  contact  with  the  wound  or  with  the  instruments,  to- 
gether with  the  instruments,  must  be  made  as  thoroughly  aseptic  as 
the  parts  to  be  operated  upon. 

Douching. — An  attentive  assistant  should  have  the  care  of  the 
douching  fluid,  discharging  it  more  or  less  constantly  on  the  cut  sur- 
faces during  the  entire  operation.  This  fluid  may  be  used  either  hot 
or  cold,  according  to  the  requirements  Of  the  individual  cases.  If,  for 
any  reason,  the  fluid  becomes  exhausted,  or  the  operation  be  tempo- 
rarily suspended,  the  incised  surfaces  must  be  at  once  enveloped  by 
towels  saturated  by  an  antiseptic  fluid. 

The  Wound. — All  bleeding  points  requiring  a  ligature  should  be 
tied  with  catgut,  the  wound  itself  closed  with  catgut,  when  prac- 
ticable, and  thoroughly  drained.     Iodoform  can  be  dusted  on  and 


TREATMENT   OF  OPERATION-WOUNDS.  53 

around  the  seat  of  the  wound,  after  which  the  kind  of  dressings  are 
applied  that  have  been  selected  to  complete  the  antiseptic  treatment. 
These  dressings  should  be  removed  as  soon  as  the  discharges  from  the 
wound  have  soiled  their  external  surface.  Furthermore,  care  must  be 
taken  that  the  external  dressings  be  kept  closely  in  contact  with  the 
surface  of  the  patient  for  a  considerable  distance  from  the  operation- 
wound  ;  otherwise,  unfavorable  atmospheric  influences  may  be  ad- 
mitted to  the  wound. 

Open  Dressing. — The  so-called  open  dressing  consists  in  washing 
the  wound  cavity  with  the  strong  carbolic-acid  solution  at  the  com- 
pletion of  the  operation,  after  which  it  is  placed  upon  a  suitable 
cushion  of  oakum,  and  over  it  is  laid  a  thin  piece  of  gauze,  which  is 
kept  moistened  with  a  solution  of  carbolic  acid.  The  wound  is  washed 
two  or  three  times  daily  by  gentle  irrigation  with  a  carbolic  solution, 
after  which  balsam  of  Peru  is  poured  into  it.  All  the  dressings  are  to 
be  kept  clean.  If  antero-posterior  coaptation  be  desired,  the  anterior 
angle  of  the  wound  is  drawn  together  by  two  or  three  stitches  to  pre- 
vent exposure  of  the  bone,  otherwise  no  mechanical  agents  are  applied 
to  the  wound. 

The  success  which  is  said  to  have  attended  this  method  in  the  hands 
of  the  late  Prof.  James  E.  Wood,  can  but  cause  the  skeptical  surgeon  to 
wonder  at  the  necessity  of  the  details  of  the  Lister  and  other  methods. 

PRECAUTIONARY   REQUIREMENTS. 

These  recpiirements,  and  their  importance,  were  stated  some  time 
previously. 

Stimulants,  of  which  brandy,  whisky,  champagne,  ammonia,  nitrite 
of  amyl,  digitalis,  etc.,  are  examples,  enter  into  common  use.  Some 
one  or  more  of  these  should  be  at  hand  during  an  operation,  irre- 
spective of  its  length  or  requirements. 

For  purposes  of  administration,  the  hypodermic  and  Davidson's 
syringes  are  most  convenient.  Under  no  circumstances  must  fluids 
be  administered  by  the  mouth,  if  the  patient  be  unconscious,  except 
by  the  medium  of  a  stomach-tube. 

Tenaculum. — Its  use  has  been  sufficiently  emphasized  to  render 
the  importance  of  its  presence  evident. 

Electric  Battery. — This  must  always  be  thought  of  when  the  na- 
ture of  the  operation,  or  condition  of  the  patient,  may  give  rise  to  the 
iabseqaent  failure  of  the  circulatory  or  respiratory  powers. 

Tracheotomy  Tube. — Although  this  is  not  necessary  to  the  per- 
formance of  tracheotomy  or  laryngotomy,  when  indications  suddenly 
calling  for  either,  yet  it  is  better  to  be  provided  with  one.  The 
surgeon  must  not  overlook  the  fact  that  the  death  of  a  patient  due  to 
the  absence  of  a  tube,  or  to  the  loss  of  time  consumed  in  seeking  for 
one,  is  unpardonable. 


54  OPERATIVE  SURGERY. 

Elastic  Bandages. — These  are  not  only  important  in  preventing 
the  loss  of  blood,  but,  as  heretofore  stated,  doubly  important,  when 
applied  to  the  limbs,  in  forcing  the  blood  contained  in  them  into  the 
center  of  circulation,  as  in  cases  of  impending  death  from  shock 
due  to  the  loss  of  blood.  They  are,  in  my  opinion,  of  greater  prac- 
tical utility  for  immediate  use,  than  the  more  elaborate  instruments 
employed  in  transfusion.  They  will  certainly  bridge  over,  better  than 
any  other  expedient,  the  interval  of  time  necessary  to  prepare  for  the 
use  of  the  transfusion  apparatus. 

Artificial  Respiration. — No  one  can  be  safely  intrusted  to  admin- 
ister an  anaesthetic,  or  to  attempt  any  operative  procedure,  who  is  not 
familiar  with  the  manipulations  necessary  to  the  proper  performance 
of  this  means  of  resuscitation.  It  is,  in  fact,  the  only  one  of  the  re- 
quirements which  can,  and  should,  be  continuously  employed  until 
the  safety  of  the  patient  is  assured,  or  until  death  is  an  established 
fact. 

Transfusion. — If  the  operation  be  of  such  a  nature  that  a  great 
loss  of  blood  is  assured,  arrangements  should  be  perfected  for  the  rapid 
performance  of  this  measure. 

Finally,  a  surgeon  should  not  begin  an  operation,  be  it  of  greater 
or  lesser  magnitude,  without  having  carefully  rehearsed  its  various 
steps  in  his  mind,  together  with  the  possible  complications  that  may 
arise,  and  the  best  means  of  combating  them. 

Precautions  of  this  kind  serve  to  distinguish  the  careful  and  con- 
scientious surgeon,  who  places  a  proper  value  upon  human  life  and  a 
just  professional  reputation,  from  the  one  who  operates  only  because 
the  opportunity  is  offered,  and  considers  the  details  tedious  or  worth- 
less, because  he  has  not  had  sufficient  patience  or  faith  to  practice 
them.  He  trusts  to  luck,  and  often  attributes  his  results  to  an  in- 
scrutable Providence  ;  more  especially  when  the  patient  succumbs. 

SPECIAL  EMERGENCIES. 

While  the  scope  of  this  work  will  not  admit  of  an  extended  con- 
sideration of  these  emergencies,  still  it  is  the  author's  earnest  desire  to 
sufficiently  emphasize  their  importance,  that  those  desiring  more  ex- 
tended information  will  seek  it  from  other  and  more  extended  sources. 
Unexpected  emergencies  not  infrequently  occur  during  the  course  of  an 
operation,  even  though  it  be  of  a  minor  character.  The  anaesthetic 
given  to  relieve  pain  may,  from  unknown  reasons,  prove  a  treacherous 
ally,  and,  by  its  unexpected  depressing  influence,  surround  the  case 
with  greater  gravity  than  that  of  the  condition  demanding  the  opera- 
tion. This  emergency,  together  with  the  suffocation  that  may  be 
caused  by  the  solid  contents  of  an  incautiously  fed  stomach  finding 
their  way  into  the  air-passages,  has  been  quite  fully  considered  in  the 
preceding  pages. 


TREATMENT   OF   OPERATION-WOUNDS.  55 

SJwcl: — The  symptoms  of  this  important  nervous  state  especially 
demand  a  careful  study  on  the  part  of  those  who  contemplate  prac- 
ticing surgery.  It  may  exist  before,  occur  during,  or  follow  an 
operation ;  and,  in  either  instance,  may  depend  on  loss  of  blood,  or 
be  the  result  of  a  physical  injury,  or  both  combined.  Shock  may  be 
slight  in  degree,  or  be  characterized  by  syncope,  which  may  be  fol- 
lowed by  collapse.  Shock  due  to  the  loss  of  blood  has  characteristics 
somewhat  distinctive  from  that  dependent  on  mutilation  of  the  soft 
parts.  In  the  former,  the  cold,  clammy  surface,  feeble,  fluttering 
pulse,  extreme  pallor  of  the  mucous  surfaces,  great  restlessnesss,  and 
sighing  respiration  are  especially  prominent. 

Treatment  of  Shock. — The  severity  as  well  as  the  cause  will  very 
much  modify  the  treatment.  If  the  shock  be  slight,  lower  the  head, 
admit  fresh  air,  and  administer  a  stimulant.  If  collapse  be  impending, 
to  the  preceding  should  be  added  hot  stimulating  enemata,  heat  to  the 
body  by  means  of  bottles  filled  with  hot  water,  or  hot  plates  placed 
upon  the  abdomen  and  chest,  hypodermic  injections  of  brandy  or  ether, 
and  inhalation  of  amyl  nitrite.  Small  doses  of  opium  can  be  cau- 
tiously administered  if  nervous  irritation  be  marked,  or  the  shock  be 
due  to  loss  of  blood.  Transfusion,  either  sanguineous  or  saline,  and 
the  application  of  Esmarch's  bandage  to  the  extremities,  comprise  the 
additional  means  to  be  employed  when  the  collapse  depends  on  the 
loss  of  blood. 

Air  in  the  Veins. — This  accident  is  associated  with  operations  upon 
the  portions  of  the  body  where  the  venous  circulation  is  markedly  in- 
fluenced by  the  force  of  aspiration,  as,  in  the  regions  of  the  neck, 
chest,  and  axillae,  where,  if  a  vein  connected  with  a  morbid  growth, 
be  nicked  while  on  the  stretch,  or  otherwise  divided,  it  may  remain 
open  sufficiently  to  admit  the  sucking  in  of  air,  by  reason  of  the  ten- 
sion of  its  walls. 

Symptoms. — The  local  symptoms  are  a  bubbling  or  hissing  sound 
at  the  seat  of  hemorrhage,  sometimes  attended  with  air-bubbles.  The 
patient  suddenly  utters  a  cry,  becomes  pallid  with  anxious  facies, 
labored  breathing,  and  livid  lips.  Eapid  insensibility  or  convulsions 
may  be  the  principal  features.  Sudden  death  not  infrequently  oc- 
curs. 

Treatment. — The  treatment  must  be  quick,  decisive,  and  persist- 
ent. Close  the  opening  at  once  with  the  finger  and  tie  the  vessel. 
Artificial  respiration  and  stimulation  as  applied  to  shock  must  be 
thoroughly  employed. 

Preventive  Treatment. — This  consists  in  taking  such  measures  as 
.-.hall  tend  to  prevent  the  entrance  of  air.  1.  Pressure  upon  the  vein 
by  the  fingers  at  its  proximal  portion  during  an  operation.  2.  Avoid 
incisions  during  inspiration,  especially  when  in  the  vicinity  of  large 
veins,  and  when  the  veins  may  be  held  open  by  disease  of  their  coats 


56  OPERATIVE   SURGERY. 

or  of  the  surrounding  tissues.     3.  If  a  vein  be  cut,  compress  it  at 
once,  and  then  apply  a  ligature  to  it. 

If  the  means  here  given  be  carefully  applied,  the  danger  of  this 
complication  need  not  annoy  the  surgeon. 


CHAPTER  IV. 

LIGATURE  OF  ARTERIES.— GENERAL   CONSIDERATIONS. 

Aeteries  are  ligatured  in  their  continuity  or  at  their  divided  ex- 
tremities. Under  this  heading,  however,  will  be  considered  the  liga- 
turing in  their  continuity  only.  Nearly  all  arteries  to  which  ligatures 
are  thus  applied  can,  from  their  association  with  the  soft  and  hard 
parts,  be  said  to  possess  certain  guides,  which,  when  carefully  adhered 
to,  indicate  with  precision  their  position  beneath  the  surface. 

The  guides  to  ligaturing  arteries  in  the  living  subject  are  practi- 
cally four  in  number  :  1.  The  linear  guide.  2.  The  muscular  guide. 
3.  The  contiguous  anatomical  guide.  4.  The  pulsation  and  color  of 
the  vessel. 

The  linear  guide  to  an  artery  is  a  line  drawn  upon  the  external  sur- 
face so  as  to  correspond  with  the  established  course  of  the  vessel  be- 
neath. Its  extremities  are  usually  indicated  by  the  relations  which 
the  vessel  bears  to  fixed  bony  prominences. 

The  muscular  guide  is  based  upon  the  relation  which  the  vessel 
bears  to  some  portion  of  a  well-developed  superficial  or  deep  muscle, 
the  outline  of  which  can  be  quite  readily  traced  if  the  muscle  be 
placed  upon  the  stretch.  If  the  border  of  a  muscle  be  given  as  the 
guide,  it  must  not  be  forgotten  that,  in  case  it  be  unusually  developed, 
or  have  a  broader  origin  and  insertion  than  common,  it  will  overlap 
the  vessel,  and  thus  may  lead  the  surgeon  astray.  Under  these  cir- 
cumstances he  must  direct  his  attention  unerringly  to  the  contiguous 
anatomical  guides,  which  include  the  relations  that  a  vessel  bears  to 
its  immediate  surrounding  parts,  and,  when  taken  in  connection  with 
its  pulsation,  lead  directly  to  it.  The  contiguous  guides  may  be  mus- 
cular, if  a  muscle  be  ascertained  to  bear  an  established  relation  to  it ; 
or  bony,  when  a  bony  prominence  is  in  close  contact  with  it ;  or  nerv- 
ous, when  a  certain  nerve  is  known  to  lie  in  a  definite  relation  with 
it ;  or  vascular,  when  vessels  of  an  established  arrangement  exist. 
And,  finally,  the  sheath  of  the  vessel  itself  becomes  a  valuable  guide 
when  it  is  present  and  considered  in  connection  with  the  others.  Some 
of  the  large  vessels,  of  which  the  common  carotid  and  femoral  arteries 
are  the  most  striking  examples,  possess  well-developed  sheaths,  while 


LIGATURE   OF  ARTERIES.— GENERAL   CONSIDERATIONS. 


57 


the  smaller  arteries  are  surrounded  by  a  greater  or  lesser  amount  of 
areolar  tissue.  The  larger  arteries,  as  the  popliteal,  femoral,  and  sub- 
clavian, are  each  accompanied  by  a  single  vein  which  commonly  runs 
in  a  definite  relation  with  them.  The  smaller  ones,  those  of  the  ex- 
tremities, etc.,  are  attended  by  satellite  veins,  known  as  the  vena? 
comites,  usually  two  in  number  ;  however,  that  is  not  invariable,  since 
three  or  more  are  often  seen.  The  vessels  are  distinguished  from  each 
other  by  the  darker  color  of  the  veins  and  the  lighter  or  pinkish  color 
of  the  artery.  If  three  vessels  are  seen,  the  middle  one  is  almost  cer- 
tain to  be  the  artery  ;  if  more  than  three  exist,  the  third  vein  usually 
rests  upon  the  artery  ;  if  pressure  be  made  upon  them,  the  veins  are 
distended,  and  the  artery  is  collapsed  on  the  distal  side  of  pressure. 
If  to  these  facts  be  now  added  the  pulsation  of  the  artery,  its  location 
is  assured.  The  operator  who  relies  exclusively  upon  the  arterial  im- 
pulse as  a  guide  may  be  led  astray  by  the  transmitted  pulsations  of 
other  vessels,  or  by  the  functional  movements  of  parts  in  which  the 
artery  is  located. 

Having  determined  the  anatomical  details,  the  portion  of  the  body 
in  which  the  vessel  is  situated,  is  placed  in  position  to  afford  all 
available  room  and  the  best  possible  light ;  the  part  of  the  vessel  is 
then  selected,  at  which  the  surgeon  feels  best  assured  of  the  absence 
of  a  branch  of  sufficient  size  to  interfere  with  formation  of  an  internal 
clot.  The  primary  incision  is  made,  the  center  of  which  should,  if 
possible,  correspond  to  the  portion  of  the  vessel  to  which  the  ligature  is 
to  be  applied.  The  length  of  the  incision  will  depend  upon  the  depth 
of  the  vessel,  and  should  always  be  of  sufficient  extent  to  afford  easy 
access  to  it.  If  the  thumb  and  finger  be  employed  to  make  tense  and 
to  steady  the  integument,  great  care  must  be  taken  to  make  the  trac- 
tion equal  on  the 
respective  sides 
(Fig.  91).  Other- 
wise, after  the  tis- 
sues are  released, 
the  incision  will  be 
outside  the  line  of 
the  vessel,  which, 
if  not  noticed,  will 
lead  the  surgeon 
a- tray  ;  besides,  its 
irregularity  will  in- 
terfere with  the  necessary  space  and  light,  as  well  as  the  subsequent 
drainage.  The  external  incision  should  be  made  with  one  sweep  of 
the  knife,  rather  than  by  repeated  incisions,  which  tend  to  chop  the 
tissues,  increasing  the  danger  of  suppuration,  and  correspondingly 
ling  the  prospects  of  union  by  first  intention. 


Fig.  91. — Primary  incision. 


58 


OPERATIVE   SURGERY. 


The  fascia  is  pinched  up  by  the  thumb-forceps,  or  tenaculum,  care- 
fully nicked  with  a  scalpel,  after  which  a  grooved  director  is  cautiously 
passed  beneath  it,  upon  which  it  is  then  divided.  The  fascia  should 
not  be  incised  the  full  length  of  the  integumentary  cut.  The  nearer 
the  approach  to  the  vessel,  the  shorter  should  be  the  line  of  the  sepa- 
ration of  the  tissues,  so  that  when  the  vessel  is  reached,  the  bottom 
of  the  wound  will  somewhat  resemble  an  inverted  triangle,  with  its 
apex  corresponding  to  the  artery. 

The  tissues  beneath  the  fascia  are  to  be  gently  separated  by  the 

fingers,  handle  of  the  scal- 
pel, or  director  ;  using  the 
knife  only  when  necessary, 
until  the  sheath  of  the  ves- 
sel is  reached,  when  a 
small  opening  is  made  into 
it — about  one  fourth  of  an 
\  inch  being  ample — of  suffi- 
cient size  to  pass  the  nee- 
dle with  ease.  This  open- 
ing is  made  by  picking  up 
the  sheath  or  condensed 
tissue  with  the  thumb-for- 
ceps, and  with  the  scalpel 
at,  or  nearly  at,  right  an- 
gles with  the  forceps,  care- 
fully cutting  out  a  button- 
hole-shaped piece  of  a  suit- 
able size  (Fig.  92). 
The  borders  of  the  opening  in  the  sheath  are  then  to  be  separately 
raised,  to  inform  the  operator  if  deeper  tissues  still  surround  the  ves- 
sel ;  if  so,  they  should  be  incised  in  a  similar  manner.     When  the  pe- 


Fig.  92. — Opening  sheath  of  vessel. 


-Passing  aneurism  needle. 


Fig.  94. — Passing  probe. 


culiar  pinkish  white  appearance  of  its  coats  are  seen,  the  side  of  the 
cut  in  the  sheath  nearest  to  the  contiguous  vein  should  be  grasped  and 
raised  by  the  forceps,  and  the  aneurism  needle,  or  probe,  armed  with 


LIGATURE   OF    ARTERIES.— GENERAL   CONSIDERATIONS. 


59 


a  ligature,  carefully  passed  around  the  vessel,  being  carried  from  the 
contiguous  vein  (Fig.  94).  When  the  advancing  end  of  the  ligature 
appears  at  the  opposite  side  of  the  vessel,  it  may  be  seized  and  brought 
through  by  forceps,  and  the  aneurism  needle  withdrawn.  If  the  ves- 
sel be  sufficiently  superficial,  the  ligature  can  be  passed  through  the 
eye  of  the  needle  after  its  passage  beneath  the  artery  (Fig.  93).  If  now 
all  doubts  be  settled  as  to  the  identity  of  the  vessel,  the  ligature  is  tied 
by  making  either  the  surgeon's,  or  the  reef-knot.  If  it  be  of  catgut, 
cut  both  ends  short  and  dress  the  wound  ;  if  silk,  cut  one  extremity 
short  and  allow  the  other  to  hang  from  its  most  dependent  part.  This 
extremity  should  be  secured,  so  that  it  will  not  be  unnecessarily  drawn 
upon  when  the  wound  is  dressed.  The  length  of  time  the  ligatures 
are  to  remain  depends  upon  the  size  of  the  vessel.  If  tied  with  cat- 
gut, this  element  of  the  operation  is  eliminated. 

Instruments  required  to  Ligature  Arteries. — An  ordinary  scalpel, 
a  flexible  grooved  director,  thumb-forceps,  tenacula,  retractors,  and  an 
aneurism  needle  armed  with  a  ligature  are  required. 

Retractors  vary  in  size  and  shape.  The  ones  recommended  by 
Profs.    Mott    (Fig. 

95)  and  Parker  (Fig. 

96)  are  appropriate 
for  all  practical  pur- 
poses. If  neither  be 
at  hand,  one  can  be 
devised  by  bending 
the  handle  of  the 
common  tablespoon  to  the  necessary  angle. 

Aneurism  Needle. — These  differ  in  size,  shape,  and  arrangement. 
The  simplest  form  is  combined  with  a  director  (Fig.  97)  ;  another  in 

common  use  has  a 
broader  extremity 
with  a  suitable  handle 
(Fig.  98)  ;  still  an- 
other with  adjustable 
points  for  the  pur- 
pose of  securing  deep- 
seated  vessels.  The  points  must  be  securely  screwed  into  position, 
else  the  turning  and  twisting  often  necessary  to  pass  it  may  loosen 
them,  causing  it  to  become  a  source  of  annoyance  instead  of  an  advan- 


Fig.  95. — Mott's  retractor. 


Fio.  96. — Parker's  retractor. 


1 


Fio.  97. — Combined  director  and  aneurism  needle. 


60 


OPERATIVE   SURGERY. 


tage  (Fig.  99).     Also  one  with  a  lateral  curvature  may  be  employed. 

Fig.  100  is  a  representation  of  the  safest  needle  with  movable  points 

now  in  use.  It  is 
known  as  the  "Mov- 
able Immovable  An- 
eurism Needle," 
and  also  as  the 
"  Student's  Aneu- 
rism Needle."  It 
was  devised  by 
Dr.  8.  W.  Fletch- 
er, of  Pepperell, 
Mass.,  while  a  stu- 
dent ;  hence  the 
name  sometimes 
given  to  it. 

OPERATION'S  0  2* 
SPECIAL  ARTERIES. 

Ligature  of  the 
Abdominal  Aorta. — 
This  vessel  can  be 
ligatured  at  its 
lower  two  inches — 
that  is,  below  the 
origin  of  the  inferior  mesenteric — by 
two  or  three  methods. 

Contiguous  Anatomy. — The  omen- 
tum, intestines,  peritoneum,  sympa- 
thetic nerves,  and  mesentery  lie  in 
front ;  the  left  lumbar  veins,  receptac- 
ulum  chyli,  thoracic  duct,  and  ver- 
tebral column  behind  ;  on  the  right 
Fig.  99.—- Mott's  the  inferior  vena  cava,  vena  azygos, 
needle.  an(I  thoracic  duct.     At  the  left  no 

structures  are  liable  to  be  injured. 
The  Linear  guide  to  the  vessel  is  the  linea  alba. 
Operation. — First  Method  (Cooper). — "With  the 
patient  on  the  back  and  the  legs  flexed,  make  an 
incision,  three  or  four  inches  in  length — straight  or 
curved — to  the  left  of  the  umbilicus,  to  which  the 
center  of  the  incision  may  correspond  (Fig.  102,  a, 
a),  downward  through  the  various  tissues  comprising 
the  abdominal  wall  at  this  point,  to  the  peritoneum,  dividing  each  on 
a  director.     Check  all  oozing  and  carefully  incise  the  peritoneum,  se- 


Fig.  100. 
Student's  needle. 


I 


Fig.  98. 
Syme's  needle. 


LIGATURE   OF  ARTERIES. 


61 


curing  its  borders  to  prevent  them  from  retreating  outward  behind 
the  abdominal  walls. 

Turn  the  patient  toward  the  right  side,  or  tilt  the  table  in  that 
direction,  to  aid  the  displacement  of  the  in- 
testines to  one  side  ;  scratch  through  the 
peritoneum  covering  the  vessel  carefully  at 
its  left  side,  pass  the  needle  from  the  vena 
cava  from  behind  forward,  closely  hugging 
the  vessel  and  carefully  avoiding  the  sym- 
pathetic nerves  and  inferior  vena  cava. 
This  operation  should  be  done  with  strict 
antiseptic  precautions.  If  it  be  possible, 
the  temperature  of  the  operation  -  room 
should  be  85°  F.  at  least,  and  the  room 
should  have  been  thoroughly  disinfected. 
If  it  be  necessary  to  remove  the  intestines 
from  their  cavity,  they  must  be  kept 
wrapped  in  antiseptic  gauze  wet  with  warm 
water.  Linen  cloths  wet  with  a  warm, 
though  weak,  solution  of  carbolic  acid,  or  bichloride  of  mercury 
(1-10,000),  may  be  substituted  for  the  antiseptic  gauze. 

Second  Method  (Murray). — This  leads  to  the  vessel  without  open- 
ing into  the  abdominal  cavity. 

Linear  Guide  to  the  Operation. — A  line  drawn  from  the  apex  of 


Fig.  101. — Inferior  vena  cava 
and  abdominal  aorta. 


Left 


Fio.  102. — Linear  guides  to  iliac  arteries. 


Richt. 


the  tenth  rib  downward  and  forward,  to  within  about  one  inch  of  the 
anterior  superior  spine  of  the  ilium  (Fig.  102,  b,  right). 

Contiguous  Anatomy. — The  ureter  lies  to  the  outer  side.     In  other 
respects  the  relations  of  the  vessel  are  .similar  in  both  methods. 


62  OPERATIVE   SURGERY. 

Operation. — Divide  the  various  tissues  on  a  grooved  director  down 
to  the  peritoneum  ;  the  hand  is  then  inserted  into  the  wound,  and 
the  peritoneum,  intestines,  and  ureter  are  raised  carefully  upward  and 
inward,  readily  exposing  the  vessel  to  view.  The  artery  is  then  raised 
with  the  finger  and  the  ligature  passed  as  before.  It  can  be  reached 
through  an  incision  extending  from  the  end  of  the  last  rib  to  the  an- 
terior superior  spinous  process  of  the  ilium. 

Results. — It  has  been  ligatured  ten  times,  and  in  every  instance 
has  proved  fatal,  death  occurring  from  within  three  or  four  hours  to 
ten  days. 

Ligature  of  the  Common  Hiac  Arteries.  —  These  vessels  average 
about  two  inches  in  length,  and  should  be  ligatured  at  a  point  near- 
est to  their  middle.  They  commonly  begin  at  the  left  of  the  mid- 
dle of  the  body  of  the  fourth  lumbar  vertebra,  and  pass  downward 
and  outward  to  the  sacro-iliae  synchondroses. 

Linear  Guide  to  the  Vessels. — A  line  drawn  between  the  highest 
portions  of  the  iliac  crests  corresponds  very  nearly  to  their  point  of 
origin.  Two  lines  drawn  a  little  to  the  left  of  the  center  of  this  one, 
and  carried  downward  and  outward  between,  but  a  little  nearer  the 
pubes,  than  to  the  anterior  spinous  process  of  the  ilium,  mark  the 
course  of  the  vessels  downward  (Fig.  102,  left). 

There  are  two  general  methods  of  access  to  them  ;  one  by  entering 
the  abdominal  cavity  in  front,  the  other  by  raising  the  peritoneum 
through  an  incision  made  at  the  side  of  the  abdomen. 

First  Method. — At  this  time  this  method  is  not  generally  accept- 
ed as  a  substitute  for  the  latter,  except  in  cases  where  the  latter  is  of 
doubtful  expediency.     If  the  surgeon  be  able  to  command  complete 

asepsis,  the  advisability  of  the  latter  ope- 
ration is  greatly  enhanced  ;  if  otherwise, 
it  should  not  be  attempted  unless  the 
situation  of  the  disease  calling  for  it  ren- 
ders the  former  impracticable.  The  outer 
border  of  the  rectus  muscle,  or  more  prop- 
erly the  linea  semilunaris,  is  the  best  su- 
perficial guide  to  the  vessel  in  this  meth- 
od. The  linea  semilunaris  extends  from 
the  lower  portion  of  the  seventh  rib  in 

a  slightly  outward  arched  direction 
Fig.    103.— Venous    relations    of..  i  ,      .,  .  „,-,  ,  T 

iliac  arteries.  downward  to  the  spine  of  the  pubes.     In 

a  normal  abdomen  these  lines  are  about 
three  inches  from  the  umbilicus.  An  incision  through  the  linea  alba 
below  and  even  extending  a  little  above  the  umbilicus,  may  be  em- 
ployed likewise  (Fig.  102,  a,  right).  The  relations  of  the  common  iliac 
arteries  and  veins  are  intricate  and  dissimilar  (Fig.  103),  and  should 
be  carefully  memorized. 


LIGATURE   OF  ARTERIES. 


63 


Plan  of  the  Relations  of  the  Common  Iliac  Arteries. — (Gray.) 

In  front.  In  front. 

Peritoneum.  Peritoneum. 

Small  intestines.  Sympathetic  nerves. 

Sympathetic  nerves.  Rectum. 

Ureter.  Superior  hemorrhoidal  artery. 

Ureter. 


Outer  side. 
■   Right    ">    Vena  cava, 
common  \    Right  common 

iliac  iliac  vein. 

.  artery.   J    Psoas  muscle. 

Behind. 
Right  and  left  common 
iliac  veins. 


Inner  side.  Outer  side. 

Left  common  r      Left     "i      Psoas  muscle, 

iliac  vein.  J  common  I 

iliac      f 
I  artery.  J 

Behind. 

Left  common 

iliac  vein. 


Operation. — An  incision,  five  inches  in  length,  and  three  inches  to 
the  left  of  the  median  line,  is  carefully  made  into  the  abdominal  cav- 
ity ;  the  intestines  are  pushed  aside,  a  small  opening  is  scratched 
through  the  peritoneum,  and  the  vessel  ligatured  by  passing  the  nee- 
dle from  without  inward  on  the  right  and  from  within  outward  on  the 
left  side.  That  is  to  say,  pass  it  from  the  vein  nearest  the  vessel. 
The  external  wound  is  then  closed  as  in  ovariotomy. 


Fio.  104. — Incision  for  ligaturing  common  iliac  artery,     a.  Peritoneum,     b.  Ureter, 
c.  Common  iliac  artery,     d.  Common  iliac  vein.    /.  Psoas  muscle. 

If  it  be  necessary  to  remove  the  intestines  from  the  abdominal 
cavity,  they  should  be  protected  the  same  as  in  the  ligaturing  of  tho 


64. 


OPERATIVE  SURGERY. 


abdominal  aorta,  and  under  all  circumstances  the  most  rigid  antisep- 
tic care  must  be  enforced. 

Results. — They  are,  thus  far,  sufficiently  satisfactory  to  warrant 
the  employment  of  this  method  when  other  methods  are  of  a  question- 
able utility. 

Second  Method.  — Without  opening  into  the  abdominal  cavity. 
Linear  Guide  to   Operation. — First  (Crampton).     A  line  drawn 
from  the  apex  of  the  last  rib,  downward  and  a  little  forward  nearly  to 
the  crest  of   the   ilium,  then  carried  forward  parallel  with  it  to  a 
little  below  the  anterior  superior  spine  (Figs.  102,  c,  left,  and  104). 

Second  (McKee).  A  line  drawn  downward  from  the  tip  of  the 
eleventh  rib  to  one  and  a  half  inches  within  the  anterior  superior 

spine,  then  carried  down- 
ward and  forward  and 
curved  upward,  abruptly 
terminating  above  the  in- 
ternal abdominal  ring 
(Figs.  102,  b,  left,  and  105). 
Muscular  Guide.  — 
There  is  no  superficial  mus- 
cular guide  to  the  common 
iliac  artery  except  the  rec- 
tus in  the  median  opera- 
tion. The  inner  border 
of  the  psoas  magnus  is, 
however,  an  undeviating 
and  markedly  prominent 
deep  muscular  guide.  The 
contiguous  anatomy  is  in- 
dicated by  the  plan  of  the 
preceding  method. 

Operation. — Place  the 
patient  on  the  back,  the 
body  inclined  to  the  opposite  side,  and  with  the  thighs  flexed  suffi- 
ciently to  relax  the  abdominal  walls.  By  repeated  divisions  on  the 
grooved  director,  the  various  layers  of  the  tissues  composing  the  ab- 
dominal walls  are  divided  down  to  the  fascia  transversalis,  which  is 
cautiously  raised  from  the  peritoneum  at  the  upper  end  of  the  wound, 
where  it  is  less  dense  and  less  firmly  attached,  and  a  small  opening 
made  into  it,  through  which  the  finger  or  a  large  grooved  director  can 
be  passed,  and  upon  which  the  fascia  is  divided  to  the  full  extent  of 
•  the  wound.  The  hand  of  an  assistant,  who  should  stand  on  the  op- 
posite side  of  the  body,  should  then  be  introduced  into  the  wound  and 
the  peritoneum  raised  gently  upward  and  inward,  while  the  operator, 
by  the  aid  of  the  finger  or  handle  of  the  scalpel,  separates  it  carefully 


Fig.  105. — Ligature  of  primitive  iliac  artery. 


LIGATURE   OF   ARTERIES.  (55 

from  the  tissues  beneath.  When  the  psoas  magnus  is  reached,  the 
surgeon  will  then  know  the  exact  location  of  the  artery.  If  the  exter- 
nal iliac  artery  be  first  felt,  it  is  to  be  followed  upward  to  the  common 
iliac  ;  when  the  common  iliac  is  reached,  the  areolar  tissue  surround- 
ing it  is  scratched  aside  by  the  finger  or  a  director,  and  the  needle 
passed,  the  one  with  the  adjustable  end  being  preferable. 

Dangers. — The  dangers  attending  this  operation  are  of  consider- 
able magnitude.  The  peritoneum  may  be  lacerated,  the  ureter  in- 
cluded in  the  ligature,  or  the  veins  punctured  by  the  needle.  The 
assistant  who  raises  the  peritoneum  should  keep  the  fingers  closely 
approximated,  using  both  hands,  if  necessary,  and  being  careful  that 
the  fingers  do  not  become  too  much  flexed,  else  they  may  lacerate  it. 
If  the  patient  struggle,  vomit,  or  cough,  the  peritoneum  should  be 
permitted  to  return  to  its  normal  site  until  quiet  is  again  restored. 
The  traction  necessary  to  separate  and  elevate  it  can  not  be  made  too 
carefully,  and  it  is  better  if  it  be  done  during  the  acts  of  expiration, 
since  at  this  time  less  downward  pressure  will  be  made  by  the  abdom- 
inal contents.  Large,  broad  retractors  are  sometimes  employed  for 
this  purpose,  but  they  are  much  less  reliable  than  the  hands  of  an  in- 
telligent assistant. 

The  ureter  crosses  the  artery  at  its  point  of  bifurcation  ;  but  it  is 
in  little  danger,  since  it  is  usually  raised  together  with  the  peritoneum 
and  its  subjacent  tissue.  The  veins  can  be  avoided  by  always  remem- 
bering to  pass  the  needle  from  them.  This  will  be  somewhat  difficult 
on  the  right  side,  owing  to  the  large  venous  trunks  in  close  contact 
with  it.  If  the  vein  obscures  the  arterial  trunk,  pressure  upon  it 
below  the  point  to  be  ligatured  will  diminish  its  size,  by  obstructing 
the  venous  return,  which  will  permit  the  easy  exposure  of  the  artery. 

Fallacies. — The  external  iliac  artery  may  be  mistaken  for  the  com- 
mon iliac  artery.  The  relation  of  the  sacro-vertebral  prominence  to 
the  external  iliac  artery  should  settle  this  doubt.  The  ligature  may 
be  applied  too  near  the  bifurcation,  owing  to  the  difficulty  of  finding 
it,  on  account  of  obscure  light  and  the  intimate  relation  of  the  vessels. 
Care  only  will  prevent  this  with  certainty. 

Results. — This  vessel  has  been  ligatured  sixty-eight  times,  with 
sixteen  recoveries,  giving  a  rate  of  mortality  of  about  seventy-seven 
per  cent. 

Ligature  of  Internal  Iliac  Artery. — This  vessel  is  about  an  inch 
and  a  half  in  length,  extending  from  the  bifurcation  of  the  common 
iliac  downward  and  forward  to  near  the  upper  border  of  the  great 
■acro-eoiatic  foramen. 

Methods  of  Operating. — Two  or  three  incisions  are  given  with  a 
view  of  reaching  thifl  vessel.  Either  of  the  incisions  employed  in  the 
ligature  of  the  common  iliac  will  easily  lead  to  it  ;  or,  an  incision  five 
inches  in  length,  parallel  with  the  epigastric  artery  ;  or,  a  semicircular 


QQ  OPERATIVE  SURGERY. 

incision  about  seven  inches  in  length,  two  inches  to  the  left  of  the 
umbilicus,  with  its  convexity  outward,  and  ending  just  to  the  outer 
side  of  the  external  abdominal  ring.  It  can  be  easily  tied  through  an 
incision  made  into  the  abdominal  cavity  in  the  median  line  below  the 
umbilicus. 

This  vessel  possesses  no  practical  linear  or  muscular  guide  other 
than  it  lies  to  the  inner  side  of  the  psoas  magnus. 

Plan  of  the  Relations  of  the  Internal  Iliac  Artery. — (Gray.) 


In  front. 

Peritoneum. 

Fascia. 

Ureter. 

Outer  side. 

C  Internal ) 

Psoas  magnus. 

<     iliac      > 
(  artery.    ) 

Behind. 

Internal  iliac  vein. 

Lumbo-sacral  nerve. 

Pyriformis  muscle. 

Operation. — The  tissues  are  successively  divided  in  the  line  selected 
for  the  primary  incision,  as  in  the  operation  for  ligaturing  the  primi- 
tive iliac  ;  the  peritoneum  is  elevated  in  the  same  cautious  manner,  the 
connective  tissue  scratched  away,  and  the  ligature  carried  from  within 
outward,  taking  care  to  avoid  the  ureter,  and  the  external  iliac  vein 
as  it  lies  at  the  angle  of  bifurcation  of  the  primitive  iliac  artery. 

Fallacies. — The  internal  might  be  mistaken  for  the  external  iliac 

artery ;  this  doubt,  however,  can  be 
,--'"       "~"~-,  quickly  settled  if  the  course  of  the 

latter  vessel  be  considered. 

Results. — Of  twenty-six  cases, 
eighteen  terminated  fatally,  mak- 
ing a  rate  of  mortality  of  about 
seventy  per  cent. 

Ligature  of  the  Gluteal  Artery. 
— This  vessel  passes  out  of  the  pel- 
vis at  the  upper  border  of  the  great 
ischiatic  notch,  above  the  pyrifor- 
mis muscle. 

The  Linear  guide  is  a  line  ex- 
tending from  the  posterior  superior 
spinous  process  of  the  ilium,  to  the 
trochanter  major,  when  rotated  in- 
ward.    The  artery  is  beneath  the 

Fig.  106.-Linear  guides  to  gluteal  and  junction  of  ^  *-VVex  and  middle 
sciatic  arteries.  thirds  of  this  line  (Fig.  106,  a) 


LIGATURE   OF  ARTERIES. 


67 


Fig.  107.  —  A.  Gluteus 
maximus.  B.  Gluteal  ar- 
tery.    C.  Gluteal  veius. 


Anatomically  it  lies  in  the  upper  border  of  the  notch,  which  is  a 
guide  to  it  ;  it  is  accompanied  by  its  venae  comites,  and  is  covered  by 
the  glutens  maximus  muscle. 

Operation. — Place  the  patient  on  the  abdomen,  with  the  thigh 
extended  and  rotated  inward  ;  make  an  incision 
five  inches  in  length  in  the  course  of  the  line  in- 
dicated. The  direction  of  the  incision  will  cor- 
respond to  the  course  of  the  fibers  of  the  glute- 
us maximus,  which  can  be  separated  with  the 
handle  of  the  scalpel ;  liberate  the  artery  from 
its  accompanying  veins  and  pass  the  ligature  in 
the  most  convenient  manner  (Fig.  107). 

Fallacies. — It  may  be  mistaken  for  either  of 
its  venae  comites  ;  otherwise  no  fallacy  will  occur. 
Results. — The   operation  itself  implies  but 
little  danger  to  the  patient. 

Ligature  of  the  Sciatic  Artery. — This  vessel 
escapes  from  the  pelvis  below  the  pyriformis 
muscle,  and  passes  downward  in  the  interval 
between  the  tuberosity  of  the  ischium  and  the 
trochanter  major. 

The  Linear  guides  to  the  vessel  are  two  in 
number,  one  of  which  is  drawn  parallel  with  the 

linear  guide  to  the  gluteal  artery,  only  about  an  inch  and  a  half  lower 
down.     A  second  extends  from  just  below  the  posterior  superior  spinous 

process  of  the  ilium  to  the  outer  side  of 
the  tuberosity  of  the  ischium  (b,  Fig.lOG). 
Its  deep  muscular  guide  is  the  lower 
border  of  the  pyriformis,  beneath  which 
it  descends  from  the  pelvis. 

Contiguous  Anatomy. — It  is  covered 
by  the  gluteus  maximus  ;  the  sciatic 
nerve  accompanies  it,  and  it  is  posterior 
to  the  pudic  artery. 

Operation. — An  incision  is  made 
three  or  four  inches  in  length  on  one  of 
the  lines  indicated,  the  fibers  of  the 
glutens  maximus  separated,  the  nerves  and  veins  are  pushed  aside, 
and  the  ligature  is  carried  around  the  vessel,  care  being  taken  to  avoid 
the  vein  which  lies  to  its  outer  side  (Fig.  108). 

Fallacies. — This  artery  might  be  mistaken  for  the  pudic  artery, 
which  lies  internal  to  it  ;  however,  the  direction  taken  by  the  respect- 
ive v<  - ■■'  I-  should  make  the  distinction  easy. 

Results. — The  prognosis  to  life  is  always  good  so  far  as  the  opera- 
tion it  jeli  i-  concerned. 


Fig.  103. — Ligature  of  sciatic  artery 
Passing  needle. 


•  f 


68 


OPERATIVE   SURGERY. 


Ligature  of  the  Internal  Pudic  Artery. — This  vessel  escapes  from 
the  pelvis  through  the  greater  sacro-sciatic  foramen  below  the  pyri- 
formis  muscle,  lying  internal  to  the  sciatic  artery  ;  it  then  enters  the 
pelvis  through  the  lesser  sacro-sciatic  foramen,  and  runs  along  the 
inner  surface  of  the  ramus  of  the  ischium  and  pubes,  till  it  divides 
into  its  terminal  branches. 

It  may  be  ligatured  in  two  situations :  1.  At  the  greater  sacro- 
sciatic  foramen.     2.  In  the  perineum.     In  the  first  situation,  the  in- 


Fig.  109. — Linear  guide  to  pudic  artery  in  perineum. 

cision  for  ligaturing  the  sciatic  artery  is  sufficient,  the  pudic  being 
found  internal  to  that  artery,  and  lower  down,  accompanied  by  its 

veins  and  the  pudic  nerve.  In  the  peri- 
neum, the  linear  guide  to  the  operation  ex- 
tends from  the  arch  of  the  pubes  to  the 
inner  border  of  the  tuber  ischii  (Fig.  109). 
The  artery  is  situated  about  an  inch  and  a 
quarter  above  the  margin  of  the  tuber  ischii. 
Contiguous  Anatomy. — It  runs  along 
the  outer  side  of  the  ischio-rectal  fossa,  rest- 
ing upon  the  obturator  internus  muscle, 
covered  by  the  obturator  fascia,  and  accom- 
panied by  the  pudic  veins  and  the  internal 
pudic  nerve. 

Operation. — The  patient  is  placed  in  the 
lithotomy  position,  and  an  incision  is  made 
about  four  inches  in  length  in  the  course  of 
the  line  indicated  ;  the  tissues  are  carefully 
divided  down  to  the  vessel,  which  is  then  isolated  from  its  veins  and 
nerves  and  tied  (Fig.  110).     If  care  be  not  taken  the  crus  penis  will 


Fig.   110.  —  Passing    needle 
around  pudic  artery. 


LIGATUKE   OF   ARTERIES.  QQ 

be  cut.  The  introduction  of  a  sound  into  the  urethra  will  so  posi- 
tively define  its  outlines,  that  the  danger  of  wounding  the  parts  unne- 
cessarily will  be  obviated. 

Ligature  of  the  Dorsalis  Penis  Artery. — This  artery  may  be  tied  on 
the  dorsum  of  the  penis  by  making  an  incision  an  inch  in  length  at 
either  side  of  the  dorsum  of  the  penis,  and  on  a  line  parallel  to  the  cen- 
ter of  its  long  axis.  It  is  superficial,  and  is  attended  by  its  veins  and 
nerves,  which  should  be  carefully  avoided  in  passing  the  needle. 

Ligature  of  the  External  Iliac  Artery.— This  vessel  is  about  four 
inches  long,  and  passes  obliquely  downward  and  outward,  nearly  cor- 
responding to  a  line  drawn  from  the  left  side  of  the  umbilicus  to  mid- 
way between  the  anterior  superior  spinous  process  of  the  ilium  and 
the  symphysis  pubis.  It  is  ligatured  at  about  the  middle  of  its  course. 
It  has  no  superficial  muscular  guide  ;  however,  the  psoas  magnus,  at  the 
inner  border  of  which  it  lies,  is  a  most  important  deep  muscular  guide. 
Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  External  Iliac  Artery.     (Gray.) 
In  front. 
Peritoneum,  intestines,  and  iliac  fascia. 
Spermatic  vessels. 

Genital  branch  of  gcnito-crural  nerve. 
Circumflex  iliac  vein. 
Lymphatic  vessels  and  glands. 
Outer  side.  Inner  side. 


Near 
Poupart's 
Ligament. 


Psoas  magnus.  \       „  f rna    /  External  iliac  vein  and  vas 


Iliac  fascia.  )  (  deferens  at  femoral  arch, 

v.   artery,    j 

Behind. 
External  iliac  vein. 
Psoas  magnus. 
Iliac  fascia. 

Operation. — Before  beginning  the  operation  evacuate  the  contents 
of  the  bladder  and  rectum  of  the  patient,  place  him  in  a  recumbent 
position,  with  the  thigh  slightly  flexed,  and  the  body  inclined  to  the 
opposite  side.  A  curvilinear  incision  is  then  made,  with  the  convexity 
downward,  beginning  about  an  inch  above  Poupart's  ligament,  and 
immediately  to  the  outer  side  of  the  external  abdominal  ring,  and 
terminating  on  a  level  with,  but  about  two  inches  internal  to,  the 
anterior  superior  spinous  process  of  the  ilium  (Fig.  Ill,  c).  The 
superficial  fascia,  aponeurosis  of  the  external  oblique,  the  muscular 
fibers  of  i  he  internal  oblique,  and  the  transversalis  are  separately  divided 
upon  a  grooved  director.  The  fascia  transversalis  is  now  carefully 
picked  up  with  the  thumb-forceps,  and  a  small  opening  made  through 
it,  into  which  the  director  is  inserted  and  the  fascia  divided.  The 
peritoneum  and  it-  subserous  tissue  are  then  carefully  raised  from  the 
iliac  facia,  and   pressed  upward  and  inward  until  the  outer  border  of 


70 


OPERATIVE   SURGERY. 


the  psoas  magnus  is  ascertained,  when,  after  a  little  further  separation, 
the  vessel  is  felt  pulsating  at  its  inner  margin. 


f© 


ir    i« 


Fig.  111. — Linear  guide  to  external  iliac,  Fig.  112. — Ligature  of  external  iliac, 

epigastric,  and  femoral  arteries. 

The  condensed  areolar  tissue  constituting  its  sheath  is  then  opened, 
and  the  needle  carefully  inserted  between  the  vein  and  artery,  from 
within  outward  (Figs.  112  and  113).     If  the  incision  be  made  only 

about  a  third  of  an 
inch  above  Pou- 
part's  ligament 
(Fig.  102,  aright), 
it  will  come  upon 
the  iliac  fascia 
without  coming 
in  contact  with 
the  peritoneum, 
since  the  latter  is 

Fig.  113. — Ligature  of  external  iliac,     a.  Aponeurosis  of  exter-    reflected    upward 
nal   oblique   muscle,      b.  Internal    oblique    and   transversalis  -,-,       -,  -i  ■    , 

fibers,  c.  Ganglion  sometimes  found  on  artery,  d.  Borders  and  DaCkWaramiO 
of  sheath  of  vessels,  e.  Iliac  artery.  /.  Iliac  vein.  g.  Psoas-  the  pelvis  a  little 
magnus  muscle,     h.  Deep  circumflex  artery,     i.  Deep  epigas-      i  this  noint 

trie  artery,    j.  Superficial  branches.  * 

Fallacies.— The 
external  oblique  aponeurosis  may  be  mistaken  for  the  deep  layer  of 
fascia.  The  muscular  fibers  of  the  internal  oblique  will  then  be 
mistaken  for  those  of  the  external  oblique.  If,  however,  the  direc- 
tion of  the  fibers  of  the  respective  muscles  be  recalled,  and,  further- 
more, that  the  external  oblique  has  no  muscular  fibers  in  this  situa- 
tion, the  mistake  will  be  quickly  rectified.  The  fascia  transver- 
salis may  be  mistaken  for  the  peritoneum  ;  this  fallacy  is  easily  de- 
tected by  following  it  downward,  when,  if  it  be  attached  to  Poupart's 
ligament,  or  pass  beneath  it,  it  can  not  be  the  peritoneum,  and  must 


LIGATURE   OF  ARTERIES.  71 

therefore  be  the  transversalis  fascia.  If  its  relations  to  the  previously 
divided  tissues  be  taken  into  account,  together  with  its  density  and 
opacity,  this  mistake  can  hardly  occur. 

The  iliac  fascia  may  be  mistaken  for  the  subserous  tissue,  and  be 
raised  together  with  the  peritoneum.  Under  such  circumstances  the 
vessel  will  be  raised  ujoward  together  with  the  peritoneum  and  iliac  fas- 
cia, and  will  be  felt  pulsating  in  the  roof  rather  than  the  floor  of  the 
operation  wound.  This  mistake  can  be  avoided  by  remembering  that 
the  iliac  and  psoas  muscles  are  covered  by  a  dense  fascia,  which  passes 
out  of  the  pelvis  beneath  Poupart's  ligament  to  which  it  is  attached, 
and  that  the  artery  does  not  lie  beneath  it. 

If  an  irreducible  inguinal  hernia  exist,  or  the  vein  be  adherent  to 
the  artery,  then  much  difficulty  may  be  experienced  in  properly  de- 
positing the  ligature  without  injury  to  the  intestines  or  the  vein. 
After  ligaturing,  the  wound  must  be  thoroughly  closed  by  carrying  the 
sutures  deeply  down  and  close  to  the  peritoneum,  the  superficial  tissues 
(integument  and  fascia)  being  united  separately.  If  this  be  not  done, 
the  patient  will  be  exposed  to  the  danger  of  the  occurrence  of  a  hernial 
protrusion  due  to  the  weakening  of  the  abdominal  walls.  This  is  a 
precaution  which  should  always  be  taken  in  operations  involving  the 
separation  of  the  peritoneum. 

Results. — This  vessel  has  been  ligatured  one  hundred  and  seventy- 
one  times,  with  sixty-one  deaths  ;  which  have  arisen  from  various 
causes  connected  either  with  the  operation  itself,  or  the  conditions 
calling  for  it. 

Ligature  of  the  Epigastric  Artery. — This  vessel  is  ligatured  in  one 
situation  only.  It  arises  from  the  lower  portion  of  the  external  iliac 
(i,  Fig.  113)  and  runs  upward  toward  the  umbilicus,  between  the  peri- 
toneum and  the  fascia  transversalis.  It  lies  at  the  inner  border  of  the 
internal  abdominal  ring. 

Linear  Guide. — A  line  extending  from  the  umbilicus  to  the  mid- 
dle of  Poupart's  ligament  corresponds  to  the  course  of  the  vessel. 
The  guide  to  the  first  incision  is  the  upper  border  of  the  middle  of 
Poupart's  ligament  (a,  Fig.  111). 

Operation. — An  incision  is  made,  about  three  inches  in  length, 
parallel  with  and  about  one  inch  above  Poupart's  ligament.  The  va- 
rious layers  of  the  abdominal  wall  are  then  divided  separately  upon  a 
grooved  director  until  the  fascia  transversalis  is  reached,  which  is 
opened  over  the  artery,  the  veins  separated  from  it,  and  the  ligature 
properly  placed. 

The  wound  should  then  be  carefully  closed,  and  the  patient  kept 
qniel  in  a  recumbenl  posture  until  the  tissues  are  firmly  united,  else  a 
weak  point  in  the  abdominal  trails  may  follow. 

Ligature  of  the  Deep  Circumflex  Iliac  Artery. — This  vessel  maybe 

ired  in  two  situations  :  1.  at   the  internal  abdominal  ring  ;  2,  Dear 


72  OPERATIVE   SURGERY. 

the  anterior  superior  spinous  process  of  the  ilium.  In  the  first  situa- 
tion it  may  be  tied  through  the  same  incision  as  for  the  epigastric 
artery  (a,  Fig.  111).  In  the  second  it  may  be  secured  through  an  in- 
cision made  parallel  to  Poupart's  ligament  and  just  above  it  to  the 
outer  side  of  the  course  of  the  epigastric  artery,  through  the  various 
tissue's  anterior  to  the  transversalis  fascia,  which  is  then  opened,  the 
artery  isolated  and  tied. 

Ligature  of  the  Femoral  Artery. — The  femoral  artery  extends  from 
Poupart's  ligament  to  the  lower  extremity  of  Hunter's  canal,  at  the 
junction  of  the  middle  and  lower  thirds  of  the  thigh,  where  it  termi- 
nates in  the  popliteal.  It  is  ligatured  in  three  situations  :  1,  Just  be- 
low Poupart's  ligament  ;  2,  at  the  apex  of  Scarpa's  triangle  or  about 
four  inches  below  the  ligament  ;  3,  at  its  lower  third  or  in  Hunter's 
canal.  The  most  favorable  situations  are  at  the  apex  of  Scarpa's  tri- 
angle and  in  Hunter's  canal.  However,  circumstances  often  arise 
which  necessitate  its  being  tied,  irrespective  of  the  stereotyped  situ- 
ations. 

Tlie  linear  guide  to  the  artery,  throughout  its  whole  course,  is  a 
line  drawn  from  midway  between  the  anterior  superior  spinous  pro- 
cess of  the  ilium  and  the  symphysis  pubis  to  the  inner  condyle  of  the 
femur  (Fig.  114). 

A  line  drawn  from  the  origin  of  the  adductor  longus  to  the  inser- 
tion of  the  adductor  magnus  tendon  into  the  internal  condyle  of  the 
femur  also  corresponds  to  the  femoral  artery  at  its  lower  third  (Fig. 
114,  a). 


Fig.  1 14. — Linear  guides  to  femoral  artery. 

The  Muscular  Guide. — The  sartorius  is  given  as  its  muscular 
guide  ;  the  artery  is  at  its  inner  border  in  the  upper  third,  behind  it 
in  its  middle,  and  at  its  outer  side  in  its  lower  third.  The  better 
guide  to  the  lower  third  is  the  inner  border  of  the  tendon  of  the  ad- 
ductor magnus.  This  tendon  can  be  quite  easily  felt,  but  care  must 
be  taken,  otherwise  it  will  be  mistaken  for  one  of  the  ham-string 
tendons. 


LIGATURE   OF   ARTERIES. 


73 


Contiguous  Anatomy. 

Plan  of  the  Relations  of  jhe  Femoral  Artery.     (Gray.) 

In  front. 
Fascia  lata. 

Branch  of  anterior  crural  nerve. 
Sartorius  (middle  part). 
Long  saphenous  nerve. 
Aponeurotic  covering  of  Hunter's  canal  (lower  part). 


Inner  side. 
Femoral  vein  (at  upper  part). 
Adductor  longus. 
Sartorius. 


Femoral 
artery 


a\ 


Outer  side. 
Vastus  internus. 
Femoral  vein  (at  lower  part). 


Behind. 
Psoas  muscle. 
Profunda  vein. 
Pectineus  muscle. 
Adductor  longus. 
Femoral  vein  (middle  part). 
Adductor  magnus. 


Operation — First  Situation,  Common  Femoral  (Fig.   115). — The 
vessel  can  be  ligatured  immediately  below  Poupart's  ligament  through 


Fio.  115. — Relations  of  femoral  artery. 


Fig.  116. — Ligature  of  upper  third  of  femoral 
artery. 


two  incisions  :  one  made  in  the  long  axis  of  the  vessel,  the  other  paral- 

l'l  with   the  lower  border  of  the  ligament  (//,  Fig.  111).     The  former 

however,  the  better  method.     The  patient  is  placed  upon  his  back, 


OPERATIVE   SURGERY. 


and  the  thigh  flexed  and  rotated  outward.     The  pulsation  of  the  ar- 
tery is  noted  by  the  finger,  then  an  incision  about  three  inches  in 


Fig.  1 1  *J. — Relation  of  femoral  vessels. 


length  is  made  through  the  integument  and  subcutaneous  tissues  ;  the 
fascia  lata  is  divided  on  a  director  in  the  usual  manner,  and  the  arte- 
rial sheath,  which  is  very  dense,  is  opened  and  the  needle  passed  from 
within  outward  (Fig.  116).  The  vein  will  be  noticed  at  its  inner  side, 
inclosed  in  a  common  sheath  with  it,  but  separated  from  the  artery 
by  a  fibrous  partition  (Fig.  117).  The  attention  of  the  surgeon  should 
be  directed  to  the  pinkish-white  pulsating  vessel  rather  than  to  seek- 
ing for  the  vein.  If  the  attention  and  manipulations  be  directed  toward 
the  artery,  the  vein  will  remain  uninjured  within  its  compartment. 
The  lymphatic  glands  which  are  encountered  should  be  drawn  aside. 

Second  Situation. — This  is  at  the  apex  of  Scarpa's  triangle,  or  about 
four  inches  below  Poupart's  ligament.  The  saphenous  vein  runs  along 
the  inner  side  of  this  region  ;  its  location  can  be  determined  by  press- 
ing it  above,  which  will  cause  it  to  be  distended.  Place  the  limb  as  in 
the  preceding  operation,  and  make  an  incision  about  four  inches  in 


LIGATURE   OF  ARTERIES. 


75 


length  along  the  inner  border  of  the  sartorius  muscle  ;  divide  the  tis- 
sues down  to  the  fascia  lata,  draw  the  sartorius  to  the  outer  side,  and 
the  pulsations  of  the  vessel  will  be  seen  beneath  the  fascia ;  cautiously 
open  the  fascia  lata  and  the  sheath  of  the  vessel,  and  pass  the  needle 
from  within  outward.  The  vein  lies  to  the  inner  side,  somewhat  more 
posteriorly  than  above  (Figs.  118  and  119). 

Third  Situation  or  in  Hunter's  Canal. — Flex  the  thigh  on  the 
pelvis  and  the  leg  on  the  thigh, 
with  the  thigh  rotated  outward; 
an  incision  is  then  made  along 
the  outer  border  of  the  tendon 
of  the  adductor  magnus,  begin- 
ning at  a  point  a  little  below  the 
junction  of  the  middle  and  lower 
thirds  of  the  thigh,  and  extend- 
ing upward  (Fig.  114,  a),  about 
four  inches  in  length,  through 
the  integument  and  fascia,  when 
the  tendon  will  be  readily  felt. 
If  the  sartorius  be  in  the  way,  it 
should  be  drawn  to  the  inner 
side.  Any  intervening  soft  parts 
are  pushed  aside,  and  the  fibrous 
canal  in  which  the  artery  is  con- 
tained will  be  exposed,  formed 
by  the  tendon  of  the  adductor 
magnus  with  the  inner  border  of 
the  vastus  internus  and  the  fi- 
brous reflections  extending  between  them 
I 


Fig.  118. — Ligature  of  femoral  artery  at 
apex  of  Scarpa's  triangle. 


Yin.  l  ]  9.— Ligature  <>f  femoral  artery  at  apex  of  Scarpa's  tri- 
angle. «.  Superficial  aponeurosis.  >>.  Inner  border  of  sar- 
torius.   r.  Bbeatfa  of  artery.    <l.  Femora]  artery,    f.  Long 

saphenous  nerve.     <j.  Internal   saphenous  vein.     It.   Fem- 
oral vein. 


The  canal  is  cautiously 
opened,  and  the  long 
saphenous  nerve  is 
seen  resting  upon  the 
vessel ;  this  is  drawn 
aside  and  the  needle 
passed  from  without 
inward,  the  vein  now 
leing  located  poste- 
riorly and  externally 
(Figs.  120  and  1 2 1 ). 
The  vessel  can  1)*'  lig- 
atured in  this  situa- 
tion by  making  an 
incision  of  a  similar 
length  on  the  linear 
guide     before   re  pre- 


76 


OPERATIVE   SURGERY. 


/-;" 


seuted  (Fig.  114,  b).     It  is  not  so  easily  secured,  howeyer,  as  by  the 

method  just  stated. 

Fallacies.—  The  sartorius  may  be  mistaken  for  the  other  muscles 

lying  in  its  course.  If,  how- 
ever, it  be  recollected  that  no 
"': '^  other  muscles  run  in  the  same 
direction  on  the  anterior  sur- 
face of  the  thigh,  and  that  it 
is  superficial  throughout  its 
whole  course,  no  great  confu- 
sion can  arise  from  this  falla- 
cy. The  lymphatic  glands 
that  lie  over  the  sheath  of  the 
vessel  in  the  upper  portion  of 
its  course  may  be  mistaken  for 

Fig.  120.— Ligature  of  femoral  artery  in  Hunter's    ^e  vessel  itself,  owing  to  their 

color  and  to  the  transmitted 
pulsation.  These  are  irregular,  movable,  and  can  be  raised  upward, 
when  their  apparent  pulsation  will  cease  ;  moreover,  the  artery  is  be- 
neath the  fascia 
lata,  and  they 
are  above  it. 

The  tendon 
of  the  adductor 
magnus  may  be 
mistaken  for  the 
tendon  of  the 
semimembrano- 
sus or  semi  ten  - 
dinosus.       This 

mistake  will  be  Fig.  121. — Ligature  of  femoral  artery  in  Hunter's  canal,  a.  Sartorius 
avoided  if  the  muscle,  pushed  outward,  b.  Aponeurosis  of  Hunter's  canal,  c. 
,      A       ,     ,  ,       Femoral  artery,     d.  Long  saphenous  nerve  pushed  backward  and 

tenoLon  be  traced.      outward,     e.  Anastomotica  magna,    f.  Femoral  vein, 
by     palpation 

downward  ;  the  two  latter  will  pass  behind  the  internal  condyle,  while 
the  former  will  be  found  inserted  into  it.  Care  must  be  taken  in  liga- 
turing the  artery  at  the  apex  of  Scarpa's  triangle  not  to  make  the  in- 
cision too  low  down.  The  width  of  the  hand  below  Poupart's  liga- 
ment is  a  good  practical  guide  to  its  apex.  In  ligaturing  the  artery  in 
Hunter's  canal,  it  should  be  remembered  that  the  canal  is  located  but 
a  little  below  the  middle  third  of  the  thigh,  otherwise  the  incision 
will  be  made  too  low  down,  and  the  upper  portion  of  the  popliteal 
artery  secured  instead. 

In  a  very  small  number  of  cases  (four)  the  femoral  has  been  double  ; 
in  a  like  number  it  passed  behind  instead  of  in  front  of  the  thigh.     If 


LIGATURE   OF   ARTERIES. 


77 


it  be  double,  the  portion  found  will  be  smaller  than  normal,  and  the 
object  for  which  the  ligature  is  applied  will  not  be  accomplished.  If 
the  vessel  be  not  found  in  its 
common  location  it  will  be 
necessary  to  seek  for  it  else- 
where. Deep  pressure  may 
enable  one  to  detect  the  site 
of  its  anomalous  situation. 

Results.  —  The  common 
femoral  has  been  ligatured 
eight  times  for  aneurism,  with 
a  rate  of  mortality  of  twenty- 
five  per  cent.  The  superficial 
femoral  has  been  tied  two  hun- 
dred and  four  times,  with  a 
mortality  of  fifty  cases. 

Ligature  of  the  Deep  Fem- 
oral Artery,  or  the  Profunda. 
— This  vessel  usually  comes  off 
from  the  common  trunk  one 
or  two  inches  below  Poupart's 
ligament.  It  may  arise  above 
or  even  four  inches  below  this 
ligament.  There  is  no  known 
manner  of  determining  its  site 
prior  to  an  operation.  It  arises 
from  the  outer  side  of  the  com- 
mon femoral,  running  slightly 
outward,  then  downward  and  inward,  passing  behind  the  superficial 
femoral,  accompanied  by  its  vein,  which  lies  in  front  of  it  (Fig.  122). 

Operation. — This  vessel  can  be  tied  through  the  incision  for  the 
ligation  of  the  common  femoral,  and  is  to  be  sought  for  at  its  outer 
side.  When  found  it  should  be  carefully  isolated,  in  order  that  the 
ligature  may  be  applied  a  proper  distance  from  where  the  profunda 
gives  off  its  circumflex  branches. 

Fallacies. — It  may  arise  from  the  inner,  or  back  portions  of  the 
common  femoral.  If  not  found  in  the  usual  place,  it  should  be  sought 
after  in  these  latter-mentioned  situations. 

Ligature  of  the  Popliteal  Artery. — This  vessel  may  be  ligatured 
in  two  situations  :  at  its  upper  and  lower  portions.  It  is  continuous 
with  the  femoral,  beginning  at  the  junction  of  the  middle  and  lower 
thirds  of  the  thigh,  at  the  termination  of  Hunter's  canal,  and  passes 
with  a  slight  obliquity  downward  and  outward  to  the  lower  border  of 
the  popliteus  muscle. 

Linear  Guide. — The  linear  guide  begins  a  little  to  the  inner  side 


Fig.  122. — Relation  of  the  deep  to  the  superfi- 
cial femoral. 


78 


OPERATIVE   SURGERY. 


of  the  middle  of  the  upper  portion  of  the  popliteal  space,  and  termi- 
nates below  between  the  heads  of  the  gastrocnemius  muscle,  passing 
i        midway  between  the  condyles  of  the  femur 
\        (Fig.  123). 

Muscular  Guide. — The  artery  in  its  upper 
third  lies  to  the  inner  border  of  the  semi- 
membranosus ;  at  its  lower,  midway  between 
the  heads  of  the  gastrocnemius. 

Contiguous  Anatomy. — In  the  upper  third 
the  internal  popliteal  nerve  is  more  superfi- 
cial than  the  vein  and  artery.  The  vein  lies 
in  close  contact  with  the  artery,  and  between 
it  and  the  nerve.  The  artery  is  the  inner- 
most of  the  three  ;  and  is  the  most  deeply  sit- 
uated, resting  on  the  posterior  surface  of  the 
femur.  In  the  lower  third,  the  nerve  is  still 
the  most  superficial,  but  lies  upon  and  to  its 
inner  side.  The  vein  in  this  situation  is  to 
its  inner  side,  and  more  superficial  than  the 
artery,  which  rests  upon  the  popliteus  mus- 
cle. This  vessel  should  not  be  tied  at  its 
middle  third,  on  account  of  the  large  number 
of  branches  given  off  at  this  point,  together 
with  its  contiguity  with  the  knee-joint. 

Operation  in  the    Tipper   Portion   (Fig. 
123,  b). — The  patient  can  be  placed  upon  the 
popliteal  artery  and  great  face,  or,  while  on  the  back,  the  thigh  can  be 
sciatic  nerve.  weu  flexe(j  an(j  rotated  outward.     The  former 

position  is  more  convenient  for  the  surgeon,  but  is  objectionable  on 
account  of  danger  to  the  patient.  The  pa- 
tient may  be  placed  on  the  side  corresponding 
to  the  limb  to  be  operated  upon,  with  that 
thigh  extended  and  the  opposite  one  flexed 
on  the  pelvis,  when  the  safety  and  comfort 
of  both  will  be  consulted. 

An  incision  is  made,  about  four  inches  in 
length,  along  the  inner  border  of  the  semi- 
membranosus through  the  integument  and 
fascia,  and  is  deepened  by  separating  the  are- 
olar tissue  with  the  handle  of  the  scalpel  or 
the  fingers.  The  nerve  will  no  doubt  be  first 
seen,  and,  when  drawn  outward,  the  vein  will 
be  found  lying  more  deeply  and  internal  to 
it ;  if  this  be  now  carefully  isolated  and  drawn 
in  the  same  direction,  the  artery  will  be  seen  at  its  inner  side,  which 


Fig.   123. — Linear  guides  to 


/ 


:>:::; 


Fig.  124.— Ligation  of  pop- 
liteal, upper  third. 


LIGATURE   OF  ARTERIES. 


79 


must  be  separated  from  the  surrounding  tissues,  and  the  needle  carried 
from  without  inward  (Fig.  1:24). 

Operation  in  the  Lower  Portion  (Fig.  123,  c). — Make  an  incis- 
ion midway  between  the 
heads  of  the  gastrocnemius, 
carefully  avoiding  the  exter- 
nal saphenous  vein  and  nerve, 
as  they  escape  between  the 
heads  of  that  muscle  ;  sepa- 
rate the  connective  tissues 
with  the  handle  of  the  scal- 
pel, draw  the  vein  and  nerve 
to  the  inner  side,  and  pass 
the  needle  from  within  out- 


Fig.  125. — Ligation  of  popliteal,  lower  third. 


i 


ward.     Its  lower  third  may  be  tied  below  the  inner 
tuberosity  of  the  tibia. 

The  linear  guide  in  this  situation  is  continuous 
with  that  of  the  posterior  tibial  (Fig.  132),  and  the 
limb  should  be  placed  in  a  similar  position  as  for  lig- 
aturing the  posterior  tibial. 

Fallacies. — The  tendon  of  the  semitendinosus 
may  be  mistaken  for  the  tendon  of  the  semimembra- 
nosus. At  this  situation  the  semimembranosus  has 
a  large  fleshy  belly,  which  extends  much  nearer  to 
the  median  line  of  the  popliteal  space  than  the  senn- 
it /  tendinosus.  Sometimes  there  are  two  popliteal  veins, 
\            /       one  on  either  side  of  the  vessel. 

Results. — It  is  seldom  ligatured  unless  it  be  rup- 
tured, when  both  ends  must  be  tied.  Of  the  three 
or  four  cases  thus  reported,  all  terminated  unfavora- 
bly, due,  however,  to  the  nature  of  the  injury. 

Ligature  of  the  Anterior  Tibial  Artery. — It  arises 
from  the  popliteal,  just  below  the  lower  border  of 
the  popliteus  muscle,  passes  forward  between  the 
bones  of  the  leg,  above  the  interosseous  membrane, 
then  downward  on  its  anterior  suface  to  the  ankle- 
joint,  where  it  becomes  thedorsalis  pedis.     This  ves- 
sel can  be  tied  in  three  situations  :  at  its  upper,  mid- 
dle, and  lower  thirds  ;  but,  two:  the  middle  and  lower, 
Fk;.   120.  —  Linear  are  more  than  sufficient  for  all  pracl  ical  purposes, 
iffi^d  toSS         r,i"  to«"  duide  of  the  vessel  is  drawn  on  ante- 
pedis  arteries.         rior  surface  of  leg  from  the  inner  border  of  the  bead 
of  the  fibula  to  midway  between  the  malleoli  (Fig.  126). 

The  muscular  guide  is  the  outer  border  of  the  tibialis  anticus  mus- 
cle (Figs.  121  and'  128). 


80 


OPERATIVE   SURGERY. 


Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  Anterior  Tibial  Artery.     (Gray.) 
In  front. 
Integument,  superficial  and  deep  fasciae. 
Tibialis  anticus  (overlaps  it  in  the  upper  part  of  leg). 
Extensor  longus  digitorum  )  (overlap  it  slightly). 
Extensor  proprius  pollicis    ) 
Anterior  tibial  nerve. 


Inner  side. 
Tibialis  anticus. 
Extensor  proprius  pollicis 

(crosses  it  at  its  lower 

part). 


j      Anterior      j 
i  tibial  artery.  > 


Outer  side. 
Anterior  tibial  nerve. 
Extensor  longus  digitorum. 
Extensor  proprius  pollicis. 


Behind. 
Interosseous  membrane. 
Tibia. 
Anterior  ligament  of  ankle-joint. 


Fig.  1 27. — Transverse  section,  upper  third. 
1.  Popliteus.  2,  3.  Gastrocnemius.  4. 
Soleus.  5.  Peroneus  longus.  6.  Exten- 
sor longus  digitorum.  V.  Tibialis  anti- 
cus. 8.  Tibialis  posticus.  9.  Posterior 
tibial  artery  and  venae  comites.  10. 
Posterior  tibial  nerve.  1 1 .  Anterior  tib- 
ial artery  and  venae  comites.  12.  An- 
terior tibial  nerve. 


Fig.  128. — Transverse  section,  middle  third. 
1.  Soleus.  2,  3.  Gastrocnemius.  4.  Flexor 
longus  pollicis.  5.  Peroneus  longus  and  bre- 
vis.  6.  Extensor  longus  pollicis.  7.  Exten- 
sor com.  digitorum.  8.  Tibialis  anticus.  9. 
Tibialis  posticus.  10.  Flexor  longus  digi- 
torum. 11.  Anterior  tibial  artery  and  ve- 
nae comites.  12.  Anterior  tibial  nerve.  13. 
Posterior  tibial  artery  and  venae  comites. 
14.  Posterior  tibial  nerve.  15.  Peroneal 
artery  and  venae  comites. 

Operation. — Upper  Third  (Fig.  126). — The  great  depth  of  the 
vessel  in  this  situation  renders  the  tying  of  it  one  of  the  most  tedious 
of  operations.  Unless  circumstances  demand  it,  the  ligaturing  in  this 
situation  should  not  be  attempted.  Fig.  127  shows  the  deep  relations 
of  the  vessel.  The  linear  and  muscular  guides  are  similar  to  those  of 
the  middle  third. 

Middle  Third  (Fig.  126,  a). — The  artery  in  this  situation  lies  quite 
deep,  and  a  good  light  must  be  had  to  see  the  bottom  of  the  operation 


LIGATURE   OF   ARTERIES. 


81 


wound.    Place  the  patient  on  the  hack  with  the  thighs  extended,  the  leg 

turned  inward,  and  the  foot  forcibly  extended 

to  mark  the  outlines  of  the  tibialis  anticus 

muscle.     Make  an  incision  four  or  five  inches 

in  length  on  the  line  indicating  the  course  of 

the  artery,  down  to  the  fascia,  which  is  then 

divided  on  a  director.  The  aponeurosis  is  then 

divided  along  the  line  of  apposition  between 

the  tibialis  anticus  and  the  extensor  longus 

digitorum ;   it  should    likewise  be   divided 

transversely  to  admit  of  the  wider  separation 

of  these  muscles.    The  foot  is  now  flexed,  and, 

with  the  finger,  or  handle  of  the  scalpel,  the 

line  of  separation  is  extended  directly  down 

to  the   vessel  ;  separate  the  surfaces  of  the 

wound  with  spatulae,  when  the  artery,  with 

its  nerve  and  veins,  will  be  seen,  the  nerve 

being  in  front  and  to  the  outer  side  ;  sepa- 
rate the  veins  from  the  artery,  draw  the  nerve 

aside,  and  pass  the  ligature  from  without  in- 
ward (Fig.  129). 

Operation  at  the  Lower  Third  (Fig.  126, 

b). — With  the  limb  as  in  the  preceding  in- 
stance, extend  the  foot  to  mark  the  course  of 

the  tendon  of  the  tibialis  anticus  ;  make  an 

incision  along  the  external  border  of  the  ten- 
don on  the  linear  guide  about  three  inches  in 
length.  Divide  the  fascia  on  a  director,  and  seek 
with  the  finger  for  the  space  between  the  tibialis 
anticus  and  the  extensor  proprius  pollicis  which 
has  crossed  to  the  inner  side  of  the  vessel ;  flex  the 
foot,  separate  these  muscles,  and  the  artery  will  be 
seen  accompanied  by  its  veins  and  nerve,  the  latter 
lying  in  front  and  a  little  to  the  outer  side  ;  iso- 
late the  artery,  and  place  the  ligature  by  passing  it 
from  without  inward. 

Fallacies. — The  outer  surface  of  the  head  of  the 
tibia  may  be  mistaken  for  the  head  of  the  fibula, 
which  will  bring  the  linear  guide  too  far  to  the  in- 
ner side  of  the  leg,  and  cause  the  incision  to  be 
made  over  the  belly  of  the  tibialis  anticus  muscle. 
To  avoid  thifl  it  must  be  remembered  that  the  head 
of  the  fibula  is  more  posteriorly,  and  constitutes 
the  most  external  bony  prominence  at  this  point. 
pedie  artery.  The  septum  between  the  tibialis  anticus  and  the 

8 


Fig.  129. — Ligature  of  anterior 
tibial,  middle  third. 


1 


LI  \\ 


82 


OPERATIVE   SURGERY. 


extensor  longus  digitorum  may  be  indistinct  or  absent ;  then  the  outer 
border  of  the  tibialis  anticus  can  be  determined,  1,  by  forcible  exten- 
sion of  the  tarsus ;  2,  by  determining  its  limits  by  the  resistance  to 
lateral  pressure  ;  3,  the  line  indicating  the  interspace  may  be  seen  at 
the  lower  extremity  of  the  incision  when  not  visible  above. 

The  vessel  may  be  rudimentary  or  absent ;  it  may  run  more  super- 
ficially than  common.  So  long,  however,  as  it  keeps  in  the  proper 
line  its  pulsations  will  lead  to  its  detection. 

Ligature  of  the  Dorsalis  Pedis  Artery.— This  vessel  is  a  continu- 
ation of  the  anterior  tibial  (Fig.  126,  c),  beginning  at  the  ankle-joint 
and  passing  downward  between  the  metatarsal  bones  of  the  great  and 
second  toes.  It  is  tied  in  one  situation,  and  on  a  line  which  is  a  direct 
continuation  of  the  linear  guide  to  the  anterior  tibial. 

The  muscular  guide  is  the  outer  border  of  the  tendon  of  the  ex- 
tensor proprius  pollicis  (Fig.  130). 

Contiguous  Anatomy. 

Plan  op  the  Relations  of  the  Dorsalis  Pedis  Artery.     (Gray.) 
In  front. 
Integument  and  fascia. 
Innermost  tendon  of  extensor  brevis  digitorum. 

Tibial  side.  Fibular  side. 

Extensor  proprius  pollicis.        (      Dorsalis      )         Extensor  longus  digitorum. 
i  pedis  artery,  f         Anterior  tibial  nerve. 

Behind. 
Astragalus. 
Scaphoid. 
!  Internal  cuneiform, 

and  their  ligaments. 

Operation. — Extend  the  tarsus  and  forcibly 
s--;|  flex  the  great  toe  to  make  prominent  the  ten- 
f  don  of  the  extensor  proprius  pollicis  ;  make  an 
incision  about  three  inches  in  length  along  its 
outer  border,  commencing  from  the  bend  of 
the  ankle  ;  divide  the  fascia  on  a  director,  when 
the  fleshy  inner  portion  of  the  extensor  brevis 
digitorum  will  be  seen  ;  this  should  be  drawn 
outward,  when  the  artery  and  its  satellite  veins 
will  appear ;  separate  the  artery  from  them, 
and  pass  the  needle  as  best  suits  the  conven- 
ience of  the  operator  (Fig.  131). 

Fallacy. — It  may  pass  outside  of  the  line 
indicating  its  proper  course. 

Ligature  of  the  Posterior  Tibial  Artery. — 
This  is  an  artery  of  considerable  size  which 


Fig.  131.— Ligature  of  dor- 
salis pedis. 


LIGATURE   OF   ARTERIES. 


83 


comes  from  the  popliteal  at  the  lower  border  of  the  popliteus  muscle  ; 
it  passes  obliquely  to  the  tibial  side  of  the  leg,  goes  down  between  the 
superficial  and  deep  layers  of  muscles  to  a  point  midway  between  the 


Fig.  182. — Linear  guide  to  posterior  tibial. 


internal  malleolus  and  inner  tuberosity  of  the  os  calcis,  where  it 
terminates  a  little  further  on  in  the  external  and  internal  plantar  ar- 
teries. It  may  be  ligatured  in  three  situations  :  at  its  middle  third,  at 
its  lower  third,  and  as  it  passes  behind  the  inner  malleolus. 

Tlie  linear  guide  of  this  vessel  is  drawn  from  the  middle  of  the 
popliteal  space  to  midway  between  the  inner  malleolus  and  tuberosity 
of  the  os  calcis.  This  guide  is  not  a  feasible  one,  since  to  reach  the 
artery  by  cutting  upon  it  necessitates  the  division  of  the  fibers  of  the 
muscles  of  the  calf  of  the  leg. 

Tlie  linear  guide  to  the  operation  is  made  by  drawing  a  line  three 
fourths  of  an  inch  behind  the  posterior  border  of  the  tibia  in  the 
upper  and  lower  thirds,  and  from  its  upper  to  its  lower  extremity 
(Fig.  132). 

Tlie  Muscular  Guide. — At  its  middle  third  it  lies  beneath  the  so- 
leus  ;  at  its  lower  third  to  the  outer  border  of  the  flexor  longus  digi- 
torum. 

Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  Posterior  Tibial  Artery.     (Gray.) 
In  front. 
Tibialis  posticus. 
Flexor  longus  digitorum. 
Tibia. 
Ankle-joint. 


Inner  side. 

Posterior  tibial  nerve, 

upper  third. 


(      Posterior      | 
(  tibial  artery.  ) 

Behind. 
Gastrocnemius. 
Soleus. 
Deep  fascia  and  integument. 


Outer  side. 
Posterior  tibial  nerve, 
lower  two  thirds, 


84 


OPERATIVE   SURGERY. 


Operation  at  its  Middle  Third  (Fig.  132,  c).— Place  the  patient  on 
the  back,  flex  the  leg  on  the  thigh  and  the  thigh  on  the  pelvis,  so  that 


Fig.  134. — Ligature  of  posterior  tibial,  middle  third,  a.  Fascia 
and  fat.     b.  Gastrocnemius  muscle,     c.  Cellular  tissue,     d. 
Soleus  muscle  and  its  aponeurosis,     e.  Sheath  of  vessels. 
/.  Posterior  tibial  artery,    g.  Vense  comites.     h.  Posterior 
;.  tibial  nerve. 

the  leg  will  lie  on  the  outer  side.    Make  an  incis- 
ion on  the  linear  guide  to  the  operation,  about 

Fig.  133. — Ligature  of  pos-   „  ,        .     ,         ,,        ,.    . ,     ,,       -,  „ 

terior  tibial,  middle  third,  four  inches  in  length  ;  divide  the  deep  fascia,  rec- 
ognize the  inner  border  of  the  gastrocnemius,  be- 
neath which  will  be  seen  the  fibers  of  the  soleus,  which  should  be  di- 
vided on  a  director,  down  to  the  pale  yellow  aponeurosis  on  its  under 

surface  ;  separate  the  fibers  of  the  soleus 
and  make  an  opening  through  its  apo- 
neurosis, about  one  inch  from  the  inner 
§  border  of  the  tibia,  of  sufficient  size  to 

expose  the  artery,  which  is  found  be- 
neath, attended  by  its  veins  and  the  pos- 
terior tibial  nerve  (Fig.  133)  ;  draw  the 
nerve  to  the  outer  side,  separate  the  ves- 
sel from  the  veins,  and  pass  the  needle 
from  without  inward  (Fig.  134). 

Operation  at  the  Lower  Third  (Fig. 
132, 1). — Place  the  limb  as  before  ;  make 
an  incision  in  the  course  of  the  linear 
guide  about  three  inches  in  length  ;  di- 
vide the  integument  and  fascia  in  the 
usual  manner  ;  separate  the  borders  of 
the  wound,  then  divide  the  aponeurosis 
(which  binds  down  the  deep  layer  of 
muscles)  at  about  one  inch  from  the  pos- 
terior border  of  the  tibia,  push  aside  the  fat,  and  the  vessel,  with  its 


Fig.  135. — Ligature  of  posterior  tib- 
ial, lower  third. 


LIGATURE   OF  ARTERIES.  85 

nerve  and  veins,  will  be  found  at  the  outer  border  of  the  flexor  longus 
digitorum.  Separate  the  vessel,  push  the  nerve  to  the  outer  side, 
and  pass  the  needle  from  without  inward  (Fig.  135). 

Operation  between  the  Os  Calais  and  Internal  Malleolus. — Place 
the  foot  on  the  outer  surface  and  make  a  curved  incision  about  three 
inches  in  length,  with  the  concavity  uppermost,  and  its  center  at  a 
point  midway  between  the  malleolus  and  the  inner  tuberosity  of  the 
os  calcis  (Fig.  132,  a).  Divide  the  fascia  and  the  internal  annular 
ligament  on  a  director,  using  caution  with  the  director,  since  the  ar- 
tery lies  beneath  the  ligament ;  isolate  the  vessel  from  the  veins  and 
pass  the  needle  from  without  inward.  In  passing  through  the  super- 
ficial tissues,  some  small  branches  of  the  long  saphenous  vein  may  be 
divided,  unless  caution  be  used.  In  old  people  both  these  and  the 
venae  comites  often  become  varicose,  which  increases  the  difficulty  of 
finding  and  isolating  the  artery.  It  is  better  not  to  attempt  to  liga- 
ture it  in  this  situation  if  evidences  of  varicosities  exist. 

Fallacies. — The  posterior  tibial  maybe  rudimentary  or  absent.  In 
either  instance  the  peroneal  is  usually  increased  in  size. 

Ligature  of  the  Peroneal  Artery. — It  arises  from  the  posterior  tibial 
about  an  inch  below  the  popliteus  muscle,  passes  obliquely  outward  to 
the  inner  border  of  the  fibula  (Fig.  128),  along  which  it  descends 
to  the  lower  third  of  the  leg,  and  is  finally  distributed  to  the  outer 
side  of  the  ankle.  It  may  be  ligatured  at  the  middle  third  of  the 
leg. 

The  linear  guide  is  a  line  drawn  from  the  posterior  border  of  the 
head  of  the  fibula  to  the  external  border  of  the  tendo  Achillis  at  its 
insertion. 

Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  Peroneal  Artery.     (Gray.) 

In  front. 
Tibialis  posticus. 
Flexor  longus  pollicis. 
Outer  side. 


Fibula.  j  Peroneal  > 

(    artery.    ) 


Behind. 
Soleus. 
Deep  fascia. 
Flexor  longus  pollicis. 


Operation. — Extend  the  foot  and  make  an  incision  about  four 
inches  in  length  along  the  line  indicated,  parallel  with  the  external 
border  of  the  fibula,  Separate  the  attachments  of  the  soleus  and  tin1 
flexor  longus  pollicis  from  each  other,  when  the  artery  will  be  found 
at  the  inner  side  of  the  flexor  longus  pollicis  close  to  the  fibula, 


86 


OPERATIVE   SURGEKY. 


Fallacies.—  It  may  be  absent ;  this  is,  however,  very  rare.  It  may 
be  overlooked,  and  the  posterior  tibial  found  instead.  If  its  close  re- 
lation to  the  fibula  be  remembered,  this  mistake  will  not  occur. 

Ligature  of  the  Innominate  Artery.— The  innominate  artery  arises 
from  the  beginning  of  the  transverse  arch  of  the  aorta  in  front  of  the 
left  common  carotid,  passes  obliquely  upward  and  outward  to  the  up- 
per border  of  the  right  sterno-clavicular  articulation,  where  it  divides 
into  the  right  common  carotid  and  right  subclavian.  It  has  no  prac- 
tical linear  or  muscular  guides. 

Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  Innominate  Artery.    (Gray.) 

In  front. 
Sternum. 

Sterno-byoid  and  sterno-thyroid  muscles. 
Remains  of  thymus  gland. 

Left  innominate  and  right  inferior  thyroid  veins. 
Inferior  cervical  cardiac  branch  from  right  pneumogastric  nerve. 


Right  side. 

Right  vena  innominata. 
Right  pneumogastric  nerve. 
Pleura. 


j  Innominate 
(      artery. 

Behind. 
Trachea. 


Left  side. 

Remains  of  thymus. 
Left  carotid. 


Operation. — Numerous  incisions  have  been  given  for  gaining  ac- 
cess to  the  vessel.  The  one  which  is  best  calculated  to  afford  the 
requisite  amount  of  room  was  employed  by  the  late  Valentine  Mott 

(Fig.  136,  d).  Place 
the  patient  on  the 
back,  with  the 
shoulders  somewhat 
raised,  and  the  head 
turned  to  the  oppo- 
site side.  An  incis- 
ion is  then  made 
three  inches  in 
length,  extending 
along  the  upper  bor- 
der of  the  clavicle 
to  opposite  the  cen- 
ter of  the  episternal 
notch.  This  is  joined 
by  another  of  a  sim- 
lar  length  directed 
along  the  anterior  portion  of  the  sterno-mastoid  muscle.  This  trian- 
gular flap,  consisting  of  the  integument,  superficial  fascia,  and  pla- 


136. — Linear  guides  to  arteries  of  neck. 


LIGATURE   OF   ARTERIES.  87 

tysma,  is  turned  upward  and  outward.  The  portions  of  the  sterno- 
cleidomastoid, corresponding  to  the  horizontal  incision,  and  the  ster- 
no-hyoid  and  sterno-thyroid  muscles,  are  divided  on  a  director  and 
turned  aside.  The  inferior  thyroid  veins,  if  they  now  come  into 
view,  must  be  carefully  drawn  aside,  the  deep  cervical  fascia  must  be 
carefully  torn  or  cut  through,  when  the  sheath  containing  the  com- 
mon carotid  artery,  pneumogastric  nerve,  and  internal  jugular  vein 
is  brought  into  view.  Open  the  sheath,  draw  the  vein  and  nerve  to 
the  outer  side,  and  follow  the  carotid  down  to  the  subclavian,  the 
origin  of  which  should  be  exposed.  The  upper  portion  of  the  innom- 
inata  is  then  to  be  separated  from  its  important  connections  by  the 
finger  or  a  blunt  director  ;  the  left  vena  innominata  is  depressed,  and 
the  right  vena  innominata,  right  internal  jugular,  and  pneumogas- 
tric nerve  are  carried  to  the  right,  and  then  the  aneurism  needle  is 
passed  from  below  upward,  and  from  behind,  forward  and  inward,  in 
close  contact  with  the  vessel.  It  is  suggested  to  remove  a  sufficient 
portion  of  the  upper  end  of  the  sternum  to  admit  of  the  direct  open- 
ing into  the  sheath  of  the  innominata.  It  is  thought  that  this  mea- 
sure will  the  better  preserve  the  nutritive  integrity  of  the  coats  of  the 
vessel  by  leaving  its  vascular  connections  with  the  sheath  undisturbed 
above. 

Fallacies. — If  the  innominata  be  shorter  than  usual,  the  lower 
extremity  of  the  common  carotid  may  be  tied  instead.  If  the  aorta 
arches  to  the  right  side,  the  innominata  will  be  on  the  left  side,  in- 
stead of  the  right. 

The  necessity  of  treating  all  the  veins  and  the  pleura  with  most 
judicious  care  is  emphasized  by  the  knowledge  of  the  fact,  that,  nearly 
all  the  fatal  cases  thus  far  have  died  from  pleuritis  or  secondary 
hemorrhage. 

//  ,,///.,._Thi3  vessel  has  been  ligatured  seventeen  times,  with  two 

recoveries. 

Ligature  of  the  Subclavian  Artery.— The  subclavian  artery,  on  the 
right  side,  arises  from  the  arteria  innominata,  opposite  the  junction  of 
the  right  clavicle  with  the  sternum  ;  on  the  left  side  it  arises  from  the 
arch  of  the  aorta.  These  vessels  must,  therefore,  differ  in  the  first 
part  of  their  course  in  length,  direction,  and  with  relation  to  their 
contiguous  anatomical  structures.  This  vessel  can  be  ligatured  in 
three  situations  :  between  the  inner  border  of  the  scalenus  anticus  and 
its  origin  ;  behind  the  scalenus  ;  between  its  termination  at  the  lower 
border  of  the  first  rib  and  the  outer  border  of  the  scalenus  anticus. 

Ligature  of  the  First  Portion,  Left  Side.— This  portion  has  no 
definite  linear  or  muscular  guide.  The  inner  border  of  the  scalenus 
anticus  is  important  u  leading  to  and  limiting  its  extent.  Owing 
to  its  origin  from  the  arch  of  the  aorta,  it  is  of  great  depth,  almost 
beyond    the   reach   of   a   ligature;   while   its   close   relation   to  very 


gg  OPERATIVE   SURGERY. 

important  structures— injury  to  which,  of  itself,  may  be  more 
grave  than  the  condition  for  which  the  vessel  is  to  be  tied— ren- 
der it  exceedingly  difficult  to  perform,  and  of  questionable  expedi- 
ency. 

Contiguous  Anatomy. 

Plan  of  Relations  op  First  Portion  of  Left  Subclavian  Artery.     (Gkay.) 

In  front. 

Pleura  and  left  lung. 

Pneumogastric,  cardiac,  and  phrenic  nerves. 

Left  carotid  artery. 

Left  internal  jugular  and  innominate  veins. 

Sterno-thyroid,  sterno-hyoid,  and  sterno-mastoid  muscles. 
Inner  side.  Outer  side. 

(Esophagus.  j  Left  subclavian  artery,  )  Pleura. 

Trachea.  (  first  portion.  J 


Thoracic  duct. 


Behind. 


(Esophagus  and  thoracic  duct. 

Inferior  cervical  ganglion  of  sympathetic. 

Longus  colli  muscle  and  vertebral  column. 

Operation. — Place  the  patient  on  the  back  with  the  head  extended 
and  turned  to  the  opposite  side ;  the  left  shoulder  should  be  well  de- 
pressed ;  make  an  incision  three  inches  and  a  half  in  length  along  the 
inner  border  of  the  sterno-cleido-mastoid  down  to  the  sternum ;  another, 
two  inches  and  a  half  in  length  along  the  inner  extremity  of  the  clavi- 
cle, meeting  the  former  near  the  trachea.  It  is  seen  that  this  incision 
is  substantially  the  same  as  that  for  the  ligaturing  of  the  innomi- 
nate artery  (Fig.  136,  d).  The  flap,  consisting  of  the  integument, 
superficial  fascia,  and  platysma,  is  turned  aside  ;  one  half  of  the  cla- 
vicular portion  of  the  sterno-mastoid  and  its  whole  sternal  portion  are 
then  divided  on  a  director,  bringing  into  view  the  sterno-hyoid,  sterno- 
thyroid muscles,  and,  to  the  outer  side,  the  omo-hyoid.  The  sterno- 
thyroid and  sterno-hyoid  should  be  divided  with  great  care,  after  be- 
ing liberated  from  the  fascia  which  covers  them.  The  inner  edge  of 
the  scalenus  anticus  muscle  is  now  sought  for ;  when  found,  it  will 
guide  the  finger  directly  to  the  vessel.  The  important  contiguous 
structures  are  now  drawn  inward  and  pressed  away  from  the  artery, 
using  great  caution  to  avoid  the  thoracic  duct,  which  will  be  in  the  line 
of  search,  as  it  passes  behind  the  jugular  vein  at  its  junction  with 
the  left  innominate  vein.  The  needle  is  carefully  passed  from  before 
backward.  The  great  depth  of  the  vessel  will  make  it  exceedingly 
difficult  to  pass  the  needle,  which  should  be  the  one  with  the  adjust- 
able extremity. 

Results. — Tied  by  Dr.  J.  Kearney  Eogers,  1845  ;  patient  died  from 
secondary  hemorrhage  on  the  fifteenth  day. 


LIGATURE   OF  ARTERIES. 


89 


Ligature  of  First  Portion,  Right  Side. — The  inner  border  of  the 
anterior  scalenus  leads  to  it  upon  this,  as  upon  the  left  side. 
Contiguous  Anatomy. 

Relations  of  First  Portion  of  Right  Scbcxayian  Artery.     (Gray.) 
In  front. 
Clavicular  origin  of  sterno-mastoid  muscle. 
Sterno-hyoid  and  sterno-thyroid  muscles. 
Internal  jugular  and  vertebral  veins. 
Pneumogastric,  cardiac,  and  phrenic  nerves. 


j  Right  subclavian  artery,  ) 
i  first  portion.  ) 


Beneath. 
Pleura. 


Behind. 
Recurrent  laryngeal  nerve. 
Sympathetic  nerve. 
Longus  colli  muscle. 
Transverse  process  of  seventh  cervical  or  first  dorsal  vertebra. 


Operation. — The  position  of  the  patient,  primary  incisions,  and 
dissection  are  substantially  the  same  as  the  preceding.  The  internal 
jugular  should  be  pressed  aside  and  the  needle  passed  from  below  up- 
ward and  from  before  back- 


ward,  carefully  avoiding  the 
pleura,  recurrent  laryngeal 
and  phrenic  nerves.  The  lig- 
ature of  the  vertebral  and  in- 
ternal mammary  arteries  at 
the  same  time  will  lessen  the 
danger  of  secondary  hemor- 
rhage. 

Fallacies.  — This  vessel 
may  arise  from  the  arch  of 
the  aorta,  when  it  will  be 
more  deeply  situated,  often 
passing  behind  the  oesopha- 
gus or  between  it  and  the 
trachea. 

Results.  — It  has  been  lig- 
atured thirteen  times ;  all  the 
cases  proved  fatal,  of  which 
eight  died  of  hemorrhage. 

Ligature  of  the   Second  FlG-  13*-— Linear  guides  to  arteries  of  neck  and  fare. 

and  Third  Portions. — The  linear  guide  to  the  operation  is  drawn  just 
above  the  upper  border  of  the  clavicle,  extending  between  the  poste- 
rior border  of  the  sterno-cleido-mastoid  and  the  anterior  bonier  of  the 
trapezius,  and  should  bo  about  four  inches  in  length  (Fig.  137,  a). 


90 


OPERATIVE   SURGERY. 


Muscular  Guides  to  the  Artery.— This  vessel  has  no  superficial 
muscular  guide.     The  deep  muscular  guide  is  the  outer  border  of  the 

scalenus  anticus.  The 
posterior  belly  of  the 
omo-hyoid,  while  not 
in  close  contact  with 
it,  serves  an  important 
purpose  in  directing 
the  attention  of  the 
surgeon  toward  it. 
The  situation  of  the 
outer  border  of  the 
scalenus  anticus  is 
well  indicated  by  the 
posterior  border  of  the 
sterno-cleido-mastoid, 
provided  the  latter 
muscle  be  not  uncom- 
monly developed.  The 
junction  of  the  inner  two  inches  of  the  clavicle  with  its  outer  portion 
is  a  far  more  unvarying  indication  of  the  approximate  deep  location 
of  the  outer  border  of  the  scalenus  anticus  than  is  the  former. 

The  tubercle  on  the  first  rib,  into  which  the  scalenus  anticus  is 
inserted,  is  the  guide  to  the  vessel,  the  artery  being  directly  behind  it 
(Fig.  138). 

Contiguous  Anatomy. 

Relations  of  Third  Portion  of  Subclavian  Artery.     (Gray.) 

In  front. 
Cervical  fascia. 

External  jugular,  supra-scapular,  and  transverse  cervical  veins. 

Descending  branches  of  cervical  plexus. 

Subclavius  muscle  and  supra-scapular  artery  and  clavicle. 

Above.  Beloio. 

Brachial  plexus.  j  Subclavian  artery,  \_  First  rib. 


Fig.  138. — Surgical  anatomy  of  subclavian. 


Omo-hyoid. 


third  portion. 

Behind. 
Scalenus  medius. 


Operation— Third  Portion. — Place  the  patient  on  the  back  with 
the  shoulders  elevated  from  the  table,  head  bent  backward  and  turned 
to  the  opposite  side.  Draw  the  shoulder  of  the  corresponding  side 
firmly  downward  to  the  side  of  the  patient,  and  retain  it  in  that  posi- 
tion. Compress  the  external  jugular  vein  above  the  clavicle,  long 
enough  to  cause  its  distention,  thereby  indicating  its  exact  situation. 
The  integument  is  then  drawn  evenly  downward  and  incised  upon  the 


LIGATURE   OF   ARTERIES. 


91 


Fig.  139. — Ligature  at  third  portion  of  subclavian. 


clavicle,  and  will,  when  allowed  to  retract,  carry  the  incision  upward 
to  its  proper  situation— one-half  inch  above  the  clavicle.    The  super- 
ficial fascia  and  platysma  are  then  divided  upon  a  director,  being  care- 
ful not  to  sever  the  external  jugular,  which  can  be  either  pulled  aside 
or  divided  between  two  ligatures.     The  supra-scapular  and  transverse 
cervical  veins  should  be  treated  in  the  same  manner.     The  omo-hyoid 
is  now  sought  for  and  drawn  upward,  if  necessary,  and  the  supra- 
scapular artery  avoided. 
The  deep  cervical  fascia 
is   torn  asunder  by  the 
finger-nail  or  a  director, 
and  the  outer  border  of 
the  scalenus  anticus  felt 
for  on   a  line  with  the 
outer  margin  of  the  ster- 
no-cleido-mastoid,  if  the 
latter  have  not  been  di- 
vided ;  if  so,  it  should  be 
located  as  described  un- 
der the  head  of  "  Mus- 
cular Guides  to  the  Ar- 
tery."    If  the  head  be  turned  forcibly  to  the  opposite  side,  the  scale- 
nus anticus  will  be  made  tense  and  more  prominent.     When  found, 
it  should  be  followed  downward  to  its  insertion,  when  the  finger  will 

rest  upon  the  tubercle  of 
the  first  rib,  immediately 
behind  which  the  pulsa- 
tion of  the  artery  will  be 
felt.  The  vessel  is  now 
carefully  exposed  and  the 
needle  passed  from  be- 
fore backward  (Fig.  139). 
Great  caution  should  be 
taken  not  to  interfere 
with  the  subclavian  vein, 
which  lies  in  front  of, 
and  on  a  lower  plane  than 
the  artery  (Fig.  140). 

Fallacies.—  The  ster- 
no-cleido-mastoid  may 
have  an  unusual  breadth  of  origin  from  the  clavicle,  thereby  causing 
the  incision  to  bo  made  too  far  posteriorly.  The  clavicular  measure- 
i,i». nt  will  prevent  tins  error.  The  tubercle  on  the  anterior  Burface  0* 
a  transverse  process  of  one  of  the  lower  cervical  vertebra  may  be  mis- 
taken for  the  tubercle  of  the  first  rib.     This,  however,  is  easily  recti- 


FiG.  140. — Ligature  of  subclavian  artery,  third  portion. 
a.  Anterior°border  of  trapezius  muscle,  b.  Stcrno- 
mastoid  muscle,  c.  Omo-hyoid  muscle,  d.  Scalenus 
anticu3  muscle,  e.  Aponeurotic  tissue.  /.  Subcla- 
vian vein,  partly  behind  clavicle,  ff.  Occasional  ori- 
gin of  the  supra-scapular  artery,  h.  External  jugu- 
lar vein.  i.  Inner  cords  of  the  brachial  plexus.  ,;'. 
Superficial  descending  branches  of  brachial  plexus. 
ibclavian  artery.     I.  Connective  tissue. 


92 


OPERATIVE  SURGERY. 


fied  by  remembering  that  the  rib  is  located  downward  and  backward, 
that  no  contiguous  pulsation  is  found,  and  that  the  outline  of  the 
scalenus  anticus  is  absent.  The  tubercle  may  be  absent,  and  the 
muscular  insertion  into  the  rib  must  then  be  relied  upon. 

The  artery  may  be  in  front  of  the  tubercle  and  the  vein  behind  it. 
The  pulsation  as  well  as  the  anatomical  appearances  will  determine 
the  interchange  of  situations.  The  inner  cord  of  the  brachial  plexus 
may  be  mistaken  for  the  artery.  A  little  attention  to  the  distinctive 
physical  characteristics  between  nerves  and  arteries  will  quickly  settle 
this  doubt. 

Results.— Two  hundred  and  fifty-one  cases  are  tabulated,  of  which 
one  hundred  and  thirty-four,  or  fifty-three  per  cent,  died. 

Ligature  of  the  Second  Portion.— All  the  muscular  and  linear 
guides  are  practically  similar  to  those  of  the  preceding. 

Contiguous  Anatomy. 

Plan  of  Relations  of  Second  Portion  of  Subclavian  Artery.    (Gray.) 


In  front. 

Scalenus  anticus. 

Phrenic  nerve. 

Subclavian  vein. 

Above. 
Brachial  plexus. 

(  Subclavian  artery,  ) 
1     second  portion.      ) 

Behind. 
Pleura  and  middle  scalenus. 

Below. 
Pleura. 

Operation. — The  steps  essential  to  arrive  at  the  proper  site  in  this 
instance,  are  not  varied  from  those  given  for  the  third  portion,  until 
the  outer  border  of  the  scalenus  anticus  is  well  determined  ;  the  phre- 
nic nerve  and  subclavian  vein  should  then  be  pushed  aside  and  the 
muscle  divided  (Fig.  140,  d),  when  the  retraction  of  its  fibers  will  ex- 
pose the  artery  to  view.  The  needle  is  then  passed  as  before,  closely 
hugging  the  artery,  to  a^oid  the  pleura  below  and  posteriorly. 

Fallacies. — The  vein  and  artery  may  be  transposed. 

Results. — Thirteen  cases  are  reported,  of  which  nine,  or  sixty-nine 
per  cent,  were  fatal. 

The  subclavian  should  always  be  tied  in  the  third  portion  when 
possible  ;  if  impossible,  then  the  second  should  be  selected.  The  liga- 
ture of  the  first  portion  is  unwarranted  in  view  of  the  results  here- 
tofore obtained. 

Ligature  of  the  Vertebral  Artery. — This  artery  arises  from  the 
upper  and  back  part  of  the  first  portion  of  the  subclavian,  passes 
directly  upward  along  the  anterior  surface  of  the  vertebral  column, 
and  enters  the  foramen  in  the  transverse  process  of  the  sixth  cervi- 
cal vertebra.     It  ascends  through  the  foramina  in  the  transverse  pro- 


LIGATURE   OF   ARTERIES.  93 

cess  of  all  the  vertebrae  above  this,  inclining  outward  and  upward  be- 
tween the  transverse  processes  of  the  axis  and  atlas,  and  finally  runs  in 
a  deep  groove  on  the  upper  surface  of  the  posterior  arch  of  the  atlas 
before  it  ascends  to  pierce  the  posterior  occipito-atloid  ligament.  It 
may  be  ligatured  in  three  situations  :  1,  before  entering  the  vertebral 
canal ;  2,  between  the  atlas  and  axis  ;  3,  between  the  atlas  and  the 
occipital  bone. 

1.  The  linear  guide  to  the  artery  in  the  first  situation  is  drawn 
from  the  junction  of  the  inner  fourth  with  the  outer  three  fourths  of 
the  clavicle,  to  the  posterior  border  of  the  mastoid  process.  The  deep 
guides  are  the  tubercle  of  the  transverse  process  of  the  sixth  cervical 
vertebra,  and  the  space  between  the  borders  of  the  longus  colli  and  the 
scalenus  anticus. 

Contiguous  Anatomy. 

In  front. 
Internal  jugular  vein  and  its  sheath. 
Inferior  thyroid  artery. 
Thoracic  duct  (left  side). 

Aponeurosis  between  longus  colli  and  the  scalenus  anticus. 
Vertebral  vein. 

Outer  side.  i  Vertebral  )  Inner  side. 

Scalenus  anticus.  (     artery.     )  Longus  colli. 

Behind. 
Cervical  nerves. 
Vertebral  column. 

Operation. — 1.  The  head  should  be  turned  to  the  opposite  side  and 
an  incision  about  three  inches  and  a  half  in  length  made  along  the 
anterior  border  of  the  sterno-cleido-mastoid,  terminating  at  the  upper 
border  of  the  sternum.  The  fascia  and  the  connections  between  the 
sterno-mastoid  and  sterno-hyoid  are  divided  and  these  muscles  sepa- 
rated, which  exposes  the  common  sheath  of  the  internal  jugular  vein, 
common  carotid  artery,  and  pneumogastric  nerve.  This  sheath  is  now 
carefully  separated  from  its  connections  with  the  sterno-thyroid  and 
longus  colli  muscles  and  drawn  outward.  The  parts  are  now  relaxed 
by  raising  the  head,  the  inferior  thyroid  artery  displaced,  the  tho- 
racic duct  avoided,  and  the  aponeurosis  covering  the  vessel  torn 
through,  the  vein  pushed  aside,  and  the  ligature  passed  from  within 
outward. 

Mr.  Alexander,  whose  experience  in  tying  these  vessels  on  the 
living  subject  is  greater  than  that  of  any  other  surgeon,  describes 
his  method  of  operating  in  the  following  language:  "An  incision 
three  or  four  inches  long  i-  made  in  an  upward  and  outward  direc- 
tion along  the  hollow  which  exists  between  the  scalenus  anticus  and 
the  sterno-mastoid  muscles.     The  incision  should  begin  just  outside 


u 


OPERATIVE   SURGERY. 


and  on  a  level  with  the  point  where  the  external  jugular  vein  dips 
over  the  edge  of  the  sterno-mastoid  muscle,  or,  if  the  vein  is  invisible, 
about  half  an  inch  above  the  clavicle.  The  external  vein  is  drawn 
inward  with  the  sterno-mastoid  muscle.  The  connective  tissue  now 
appearing,  the  wound  is  opened  by  a  blunt  director,  until  the  sca- 
lenus anticus  muscle,  the  phrenic  nerve,  and  the  transverse  cervical 
artery  are  seen.  It  can  not  be  too  well  remembered  that  the  pleura 
is  at  the  inner  side  of  the  wound,  while  below  lies  the  subclavian  ar- 
tery. It  is  now  only  necessary  to  separate  the  edges  of  the  scalenus 
anticus  and  the  longus  colli  muscles  to  see  the  vertebral  artery  lying 
in  the  space  between  them.  The  artery  is  generally  completely  cov- 
ered by  the  vein,  which  is  drawn  aside  and  the  artery  is  then  liga- 
tured. " 

2.  In  this  position  the  artery  is  in  a  triangular  space  formed  by 
the  rectus  posticus  major  and  superior  and  inferior  oblique  muscles. 
It  is  covered  by  the  rectus  posticus  major  and  complexus. 

Operation. — "With  the  head  turned  to  the  opposite  side  and  inclined 
forward,  make  an  incision  three  inches  in  length  along  the  posterior 
border  of  the  sterno-mastoid,  beginning  half  an  inch  below  the  mas- 
toid process.  A  second  incision  is  then  made,  beginning  at  the  upper 
fourth  of  the  first  one  and  carried  backward  and  downward  one  inch. 
The  splenius  muscle  appears  in  view  as  soon  as  the  integument  and 
fascia  are  divided  and  pulled  aside.  The  fibro-muscular  structure  of 
the  splenius  is  divided,  its  borders  separated,  the  layer  of  fat  that 
now  appears  is  pushed  aside  by  the  finger  or  handle  of  the  scalpel,  and 
the  vessel  is  seen  ;  its  branches  are  drawn  aside  together  with  those  of 
the  second  cervical  nerve,  the  artery  isolated,  and  the  needle  passed 
from  without  inward. 

3.  The  incisions  are  the  same  as  in  the  preceding,  except  that  the 
first  one  begins  half  an  inch  above  the  mastoid  process.  The  skin,  fascia, 
and  splenius  are  divided  as  before,  the  occipital  artery  appears  at  the 
upper  angle  of  the  wound,  and  is  held  aside  ;  divide  the  aponeurosis 
and  cellular  tissue,  separate  the  borders,  enter  the  triangle,  separate 
the  fatty  tissue,  and  the  artery  will  be  exposed.  Pass  the  needle  from 
behind  forward. 

Fallacy. — The  vertebral  arteries  may  enter  the  transverse  processes 
of  the  fifth  cervical  vertebra,  instead  of  the  sixth. 

Results. — These  vessels  have  been  ligatured  forty- two  times,  in 
thirty-six  of  which  three  died  ;  one  each  from  hemorrhage,  embolism, 
and  pleurisy.  When  done  for  the  cure  of  epilepsy,  about  twenty  per 
cent  were  benefited,  some  of  which  ultimately  recovered.  The  per- 
manent benefit  derived  thus  far  in  such  cases  has  not  been  sufficiently 
ample  to  warrant  the  general  adoption  of  this  measure  for  the  treat- 
ment of  epilepsy. 

Ligature  of  the  Internal  Mammary  Artery.— The  internal  mam- 


LIGATURE   OF   ARTERIES.  95 

mary  arises  from  the  first  portion  of  the  subclavian.  It  descends  he- 
hind  the  internal  jugular  and  subclavian  veins  to  the  inner  surface  of 
the  anterior  wall  of  the  chest,  resting  upon  the  costal  cartilages  about 
half  an  inch  from  the  margin  of  the  sternum.  It  ma}*  be  ligatured 
in  any  of  the  five  upper  intercostal  spaces. 

Linear  Guide. — About  one-half  inch  to  the  outer  side  of  the 
sternum  is  a  fair  indication  of  its  locality.  It  has  no  muscular 
guide. 

Operation. — Make  an  incision  two  inches  in  length  along  the  up- 
per border  of  the  costal  cartilage  and  rib.  The  integument,  fascia, 
and  pectoralis  major  muscle  are  divided  down  to  the  intercostal  mus- 
cles. Beneath  the  internal  intercostal  muscle,  surrounded  by  the 
connective  tissue,  the  artery,  accompanied  by  the  vente  comites,  will 
be  found.  The  vessel  is  isolated,  and  the  needle  carefully  passed  to 
avoid  penetrating  the  pleura.  If  the  vessel  be  tied  in  the  uppermost 
intercostal  space,  a  single  vein  will  attend  it. 

Ligature  of  the  Inferior  Thyroid  Artery.— This  vessel  arises  from 
the  thyroid  axis,  and  passes  in  a  somewhat  irregular  course  upward 
and  inward  behind  the  sheath  of  the  common  carotid  and  internal 
jugular  vein  to  the  thyroid  gland. 

TJie  linear  guide  to  the  operation  is  along  the  anterior  border  of 
the  sterno-mastoid,  as  in  ligaturing  the  common  carotid.  The  body 
of  the  fifth  cervical  vertebra,  opposite  to  which  it  enters  the  gland,  is 
an  approximate  tony  guide  to  the  vessel. 

Contiguous  Anatomy.  —  In  front,  the  common  carotid  sheath 
and  its  contents,  and  the  sympathetic  nerve ;  the  recurrent  lar- 
yngeal and  the  oesophagus ;  if  low  in  the  neck,  carefully  avoid 
the  thoracic  duct.  The  respective  tissues  are  pulled  aside  and 
the  needle  passed.  No  dangers  attend  the  ligaturing  other  than 
those  incurred  by  the  manipulation  necessary  to  arrive  at  the  ves- 
sel. 

Ligature  of  the  Axillary  Artery. — This  vessel  begins  at  the  lower 
border  of  the  first  rib  and  extends  to  the  lower  border  of  the  tendon 
of  the  latissimus  dorsi.  It  may  be  tied  in  three  situations  :  1,  above 
the  pectoralis  minor  ;  2,  behind  ;  3,  below  that  muscle.  The  first 
and  last,  however,  are  the  only  ones  at  which  the  vessel  can  be  prac- 
tically secured. 

First  Portion. — There  is  no  linear  guide  to  the  vessel.  The  linear 
guide  to  the  operation  is  located  about  one-half  inch  below  the  lower 
border  of  the  clavicle,  extending  from  within  an  inch  or  so  of  the 
items!  extremity,  outward  three  or  four  inches. 

The  muscular  guides  arc  superficial  and  deep.  The  former  is  the 
space  between  the  border  of  the  deltoid  and  pectoralis  major  muscles. 
The  hitter  U  tli'-  pectoralis  minor,  its  upper  border  corresponding  to 
the  first  portion,  etc.,  as  before  stated. 


gg  OPERATIVE   SURGERY. 

Contiguous  Anatomy. 

Rklations  of  the  First  Portion  of  the  Axillary  Artery.     (Gray.) 
In  front. 
Pectoralis  major. 
Costo-coracoid  membrane. 
Subclavius. 
Cephalic  vein. 

Outer  side.  {      Axillary      £  Inner  side. 

Brachial  plexus.  \  ^  potion.  )  AxiUar-v  veia- 

Behind. 
First  intercostal  space,  and  intercostal  muscle. 
First  serration  of  serratus  magnus. 
Posterior  thoracic  nerve. 

In  this  situation  the  artery  lies  deeply,  and  it  is  better,  if  possible, 
to  ligature  the  third  portion  of  the  subclavian. 

Operation  (Fig.  141). — Place  the  patient  upon  the  back  with  the 
head  turned  to  the  opposite  side ;  elevate  the  shoulder  and  carry  the  arm 
a  little  distance  from  the  side  of  the  chest.    Make  an  incision  about  four 

inches  in  length  on  the 
linear  guide  given  above, 
down  through  the  integu- 
ment, fascia,  and  platys- 
ma  :  separate  the  fibers  of 
the  pectoralis  major,  or  di- 
vide them  the  full  length 
of  the  wound ;  tear  apart 
the  underlying  fascia,  when 
the  pectoralis  minor  mus- 
cle will  be  brought  in  view  ; 
bring  the  arm  to  the  side 

Fig.  I41.-Ligature  of  first  portion  of  axillary.         to  relax  this  muscle,  which 

is  then  drawn  to  the  outer 
side  ;  displace  the  areolar  tissue  carefully  with  the  finger  or  a  director, 
when  the  vein  will  be  seen,  which  should  be  carried  upward  and  in- 
ward with  a  blunt  hook,  and  the  artery  will  be  noticed  beneath  it,  and 
in  close  contact  with  the  inner  cord  of  the  brachial  plexus,  which  lies 
to  its  outer  side  and  above.  The  needle  is  then  passed  from  below 
upward.  The  cephalic  vein,  which  empties  into  the  axillary  vein, 
should  be  cautiously  avoided,  as  it  passes  between  the  borders  of  the 
pectoral  and  deltoid  muscles  to  its  termination  (Fig.  142). 

Fallacies. — The  inner  cord  of  the  brachial  plexus  may  be  mistaken 
for  the  artery.  Before  tightening  the  ligature,  pressure  should  be 
made  upon  the  vessel,  and  the  effect  upon  the  radial  pulse  noted. 


LIGATURE   OF   ARTERIES. 


9T 


The  vessel  may  be 
reached  by  making  an 
incision  between  the 
borders  of  the  deltoid 
and  pectoral  muscles 
about  three  inches  in 
length,  which  should 
connect  with  the  one 
previously  made  below 
the  lower  border  of  the 
clavicle.  The  fat  and 
cellular  tissue  can  then 
be  removed  or  dis- 
placed as  in  the  pre- 
vious instance. 

Res  it  Its.  — Xo  def - 
inite  records  are  given 
of  the  results  of  this 
operation. 


Fig.  142. — Ligature- of  first  portion  of  axillary  artery,  a. 
Pectoralis  major,  divided  in  course  of  fibers,  b.  Upper 
border  of  pectoralis  minor,  c.  Deep  fascia  (costo-coracoid 
membrane),  d.  Axillary  vein.  e.  Axillary  artery.  /. 
Inner  cord  of  brachial  plexus,  g.  Acromio-thoracic  branch. 
h.  Cephalic  vein. 


Ligature  in  the  Third  Portion.  —  TJte  linear  guide  to  the  artery  is 


Fio.  143. — Linear  guide  to  axillary,  third  portion. 


a  line  extending  upward  into  the  axilla  corresponding  to  the  junction 
of  itfl  anterior  and  middle  third-  (Fig.  L43,  a). 

Muscular  Guide. — The  inner  border  of  the  coraco-brachialis. 

7 


98 


OPERATIVE   SURGERY. 


Contiguous  Anatomy. 

Relations  of  the  Third  Portion  of  the  Axillary  Artery.    (Gray.) 
In  front. 


Outer  side. 
Coraco-brachialis. 
Median  nerve. 
Musculocutaneous  nerve. 


Integument  and  fascia. 
Pectoralis  major. 


Inner  side. 
Ulnar  nerve. 

Internal  cutaneous  nerve. 
Axillary  vein. 


Axillary 

artery, 

third  portion, 

Behind. 

Subscapularis  muscle. 

Tendons  of  latissimus  dorsi  and  teres  major. 

Musculo-spiral  and  circumflex  nerves. 

Operation  (Fig.  144). — The  arm  should  be  abducted  and  rotated 
outward.    Make  an  incision  three  inches  in  length  along  the  inner 

border  of  the  coraco-brachialis  in 


line  of  the  arterial  pulsation,  ob- 
serving that  its  center  be  above 
the  anterior  fold  of  the  axilla ; 
cautiously  divide  the  tissue  upon 
a  director,  drawing  the  median 
nerve  to  the  outer,  and  the  ax- 
illary vein  to  the  inner  side  ;  pass 
the  needle  from  within  outward. 
Fallacies.  —  Large  branches 
may  be  given  off  at  this  situation, 
which  will  confuse  the  operator. 
Pressure  upon  the  vessel  prior  to 
the  tightening  of  the  ligature  will 

determine  the  influence  upon  the  circulation  beyond. 

Results. — The  operation  implies  in  itself  no  particular  danger  to 

the  patient. 

Ligature  of  the  Brachial  Artery.  —  The  brachial  artery  extends 


Fig.  144 


-Ligature  of  third  portion  of 
axillary. 


Fig.  145. — Linear  guide  of  brachial  artery. 


LIGATURE   OF  ARTERIES.  99 

from  the  lower  border  of  the  tendon  of  the  latissimus  dorsi  to  about 
one  inch  below  the  bend  of  the  elbow-joint. 

The  linear  guide  is  drawn  from  the  junction  of  the  middle  and 
anterior  thirds  of  the  axilla  to  midway  between  the  apices  of  the  bony 
condyles  of  the  humerus  (Fig.  145). 

Muscular  Guide. — At  its  upper  third  it  lies  at  the  inner  border  of 
the  coraco-brachialis  ;  in  the  middle  third,  at  the  inner  border  of  the 
biceps ;  in  the  lower  third,  at  the  inner  border  of  the  biceps  tendon. 
It  may  be  ligatured  in  three  situations  :  at  its  upper,  middle,  and 
lower  thirds. 

Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  Brachial  Artery.     (Grav.) 
In  front. 
Integument  and  fasciae. 
Bicipital  fascia,  median  basilic  vein. 
Median  nerve. 
Outer  aide.  Inner  side. 

Median  nerve.  .  Internal  cutaneous  and 

Coraco-brachialis.  J  (.  ulnar  nerve. 

Biceps.  '   a    er^'    '  Median  nerve. 

Behind. 

Triceps. 

Musculo-spiral  nerve, 

Superior  profunda  artery, 

Coraco-brachialis. 

Brachialis  anticus 

Operation —  Upper  Third  (Fig.  145,  a). — Abduct  the  arm,  and  rotate 
it  outward  ;  make  an  incision  about  three  inches  in  length  along  the  in- 
ner border  of  the  coraco-bra- 
chialis. The  artery,  being 
very  superficial,  is  quickly 
reached.  The  median  nerve 
is  drawn  to  the  outer,  and 
the  ulnar  nerve  and  basilic 
vein  to  the  inner  side  ;  sep- 
arate the  artery  from  the 
vein,    and   pass  the   needle 

7  1  ||  «raea 

from  within  outward.  T,      ,..     _.  ,.      ....      . ,,,    ,, .  , 

iiG.  14G. — Ligature  of  brachial  in  middle  third. 

Operation  in  the  Middle 
Third  (Fig.  145,  6). — Place  the  arm  as  before  ;  make  an  incision  three 
inches  in  length  along  the  inner  side  of  the  biceps  muscle  (Fig.  146). 
The  median  nerve  is  found  lying  upon  and  a  little  to  its  outer  Bide  ; 
push  it  aside,  isolate  the  artery  from  the  venaB  comites,  and  pass  the 
needle  in  the  same  direction  u  before  (Fig.  147). 

Operation  in  the  Lower  Third  (Fig.  145,  c).—  Abduct  the  arm  and 


100 


OPERATIVE  SUEGERY. 


supinate  the  forearm.     Compress  the  arm  above  to  distend  the  medi- 
an basilic  vein  ;  make  an  incision  about  three  inches  in  length  along 

the  inner  border  of  the  tendon  of 
the  biceps  ;  draw  aside  the  medi- 
an basilic  vein,  when  the  artery 
will  be  felt  pulsating  beneath  the 
bicipital  fascia  ;  a  suitable-sized 
opening  is  now  cut  through  this 
fascia,  tbe  forearm  parti  ally 
flexed,  tbe  vessel  separated  from 
its  veins,  and  the  needle  passed 
from  within  outward  (Figs.  148 
and  149). 

Fallacies.  —  The  arteries  of 
the  forearm  may  be  given  off  from 
tbe  axillary,  or  the  brachial  may 
bifurcate  high  up,  thereby  in- 
creasing the  number  of  the  large 
vessels  in  the  arm.  This  is  determined  by  the  comparative  size  of 
the  brachial,  and  the  influence  of  pressure  on  the  circulation  on  the 
distal  side  of  the  proposed  liga- 
ture.     The  brachial  may  run  to- 


1'-  — - ^ 
Tig.  147. — Ligature  of  brachial  artery,  mid 
die  third,  a.  Sheath  of  vessels  and  nerves, 
c.  Brachial  artery,  d.  Venae  cornites.  f, 
Basilic  vein.  g.  Median  nerve,  pulled  to  in- 
ner side.  k.  Internal  cutaneous  nerve,  i. 
Ulnar  nerve. 


Fig.  148. — Ligature  of  brachial  artery 
at  lower  third. 


Fig.  149. — Ligature  of  brachial  at  lower 
third,  a.  Aponeurosis  divided  and  turned 
back.  b.  Brachialis  amicus  muscle,  in- 
ner border.  c.  Sheath  of  artery,  d. 
Brachial  artery,  e.  Collateral  vein.  /. 
Median  nerve. 


gether  with  the  ulnar  nerve  be- 
hind the  inner  condyle.  If  it  be 
not  in  its  normal  site,  deep  press- 
ure may  detect  its  pulsations  elsewhere,  which,  together  with  its  effect 
on  the  circulation  beyond,  will  determine  the  size" and  site  of  the  ves- 
sel. The  incisions  in  the  upper  two  thirds  mav  be  made  too  far  in- 
ward, leading  the  surgeon  to  mistake  the  ulnar  nerve  for  the  median. 
If  the  forearm  be  flexed  and  traction  be  made  upon  either,  its  course 
will  be  determined  and  the  mistake  corrected. 

The  median  nerve  may  pass  behind  the  arterv  instead  of  in  front, 


LIGATURE   OF  ARTERIES. 


101 


■when,  if  the  circulation  from  above  be  obstructed,  the  artery  may  es 
cape  notice.     The  artery  not  unfrerpiently 
lies  deeply  between  the  brachialis  anticus 
and  biceps  muse  I  - 

Anomalous  muscular  slips  and  unusual 
muscular  development  may  obscure  the 
artery  in  its  normal  course.  In  such  in- 
stances the  pulsation  will  determine  its 
location. 

Occasionally,  especially  in  female  sub- 
jects, when  the  upper  extremity  is  mark- 
edly concave  on  its  outer  surface,  due  to 
an  unusual  length  of  the  internal  condyle, 
the  primary  incision  may  be  made  to  the 
outer  side  of  the  vessel.  If,  however,  it  be 
made  midway  between  the  tips  of  the  bony 
condyles,  irrespective  of  the  overhanging 
soft  parts,  this  error  will  not  arise. 

Results. — It  has  been  ligatured  seven- 
ty-six times  for  hemorrhage,  with  fifty-five 
recoveries. 

Ligature  of  the  Radial  Artery. — This 
artery  arises  from  the  brachial,  is  an  ap- 
parent continuation  of  it,  and  is  superficial 
in  its  entire  course.  It  may  be  ligatured 
in  any  portion  of  its  course  ;  it  is,  how- 
ever, usually  ligatured  in  three  situations 
— at  the  upper  and  lower  thirds,  and  at 
the  wrist. 

The  linear  guide  (Fig.  150,  a,  b)  to  this 
vessel  is  drawn  from  midway  between  the 
tips  of  the  bony  condyles  of  the  humer- 
us to  the  inner  side  of  the  extremity  of  the  styloid  process  of  the 
radius. 

TJte  museuhr  guide,  at  its  upper  portion,  is  the  inner  border  of  the 
belly  of  the  supinator  longus  muscle,  beneath  which  it  lies.  At  the 
lower  portion  of  3fl  it  lies  at  the  inner  side  of  the  tendon  of 

the  same  muscle.  The  almost  universally  recognized  pulsation  of  the 
■1  at  the  wrist  is  the  best  practical  guide  to  it  in  this  location. 
In  fact,  it  i<  only  when  abnormalities  of  size  or  situation  of  it  occur 
at  this  position  that  the  other  guides  to  it  are  taken  into  considera- 
tion in  the  living  subject,  and  under  these  circumstances  they  are  of 
but  little  aid  t<>  the  operator.  Thia  same  statement  will  apply  with 
equal  force  to  all  hat  arc  similarly  associated  witli  the  snper- 

f  the  bodv. 


Fig.  150. — Linear  gnidefl  to  radial 
and  ulnar  arteries. 


102 


OPERATIVE   SURGERY. 


Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  Radial  Artery. 
In  front. 
Integument — superficial  and  deep  fasciae. 
Supinator  longus. 


Inner  side. 
Pronator  radii  teres. 
Flexor  carpi  radialis. 


Outer  side. 
Supinator  longus. 
Radial  nerve  (middle  third). 


j  Radial  artery  \ 
(    in  forearm.    \ 

Behind. 
Tendon  of  biceps. 
Supinator  brevis. 
Pronator  radii  teres. 
Flexor  sublimis  digitorum. 
Flexor  longus  pollicis. 
Pronator  quadratus. 
Radius. 

Operation — Upper  Third  (Fig.  151). — Supinate  the  forearm  ;  press 
upon  the  arm  above  to  distend  the  superficial  veins  ;  make  an  incision 
about  three  inches  in  length  along  the  linear  guide  to  the  vessel  (Fig. 

150,  a).     After  going  through  the  fascial 
.J  the  inner  edge  of  the  supinator  longus 

M  will  be  found  extending  beyond  the  line 

|    I  and  overlapping  the  artery  ;  separate  and 

pull  this  outward,  when  the  artery  will  be 
seen  lying  between  its  veins,  with  the 
nerve  to  the  outer  side  ;  separate  the  ar- 
tery, and  pass  the  needle  from  without 
inward  (Fig.  152). 


\ 


Fig.  151. — Ligature  at  upper  third 
of  radial. 


Fig.  152. — Ligature  of  radial  artery,  upper 
third,  a.  Inner  border  of  supinator  longus. 
b.  Deep  aponeurosis,  c.  Pronator  radii  teres. 
d.  Flexor  sublimis  digitorum.  e.  Radial  ar- 
tery,   f.  Vense  comites. 


Operation  in  the  Lower  Third  (Fig.  153).— In  this  situation  the 


LIGATURE   OF   ARTERIES. 


103 


• 


Fig.  153. —  Ligature  at 
lower  third  of  radial. 


vessel  is  very  superficial,  its  well-known  pulsation  being  the  best  guide 
to  it ;  with  the  arm  placed  as  in  the  preceding  position,  make  an  in- 
cision two  inches  in  length  along  the  course  of  the  vessel  (Fig.  150, 

b).  After  the  division 
of  the  integument  and 
fascia?,  the  artery  will 
be  seen  surrounded  by 
loose  areolar  tissue,  ac- 
companied by  its  veins, 
and  lying  to  the  inuer 
side  of  the  tendon  of 
the  supinator  longus. 
Separate  the  tissues 
Fig.  154.— Ligature  of  radial  ar-  and  ligature  the  artery, 

tery,  lower  third,      a.  Flexor    passing  the  needle  from 

carpi  radiahs  muscle.     6.  Ra-    *  ° 

dial  artery,     c.  Venae  comites.    the  nerve  (Fig.  154). 

Operation  at  Apex 
of  Styloid  Process  (Fig.  155).— In  this  situation 
the  vessel  is  found  in  a  triangular-shaped  space, 
bounded  internally  by  the  tendon  of  the  extensor 
primi  internodii  pollicis  ;  externally  by  that  of 
the  secundi  internodii  pollicis,  and  the  base  cor- 
responding to  the  apex  of  the  styloid  process  of 
the  radius.  If  the  thumb  be  forcibly  extended,  the  outlines  of  the 
space  will  be  well  marked. 

Operation. — Place  the  hand  midway  between  supination  and  pro- 
nation, and,  having 
ascertained  the  exact 
situation  of  the  ten- 
don of  the  extensor 
primi  internodii  polli- 
cis, make  an  incision 
along  its  outer  border 
about  an  inch  in 
length  ;  use  care  not 
to  divide  the  superfi- 
cial veins.  The  areo- 
lar tissue  and  the  ex- 
fcenaor  primi  internodii  pollicis  are  pushed  aside,  and  the  vessel  found 
somewhat  deeply  situated.  The  needle  can  be  carried  in  either  direction. 
JPaUacka.-— The  radial  artery  may  lie  upon  the  fascia  and  supinator 
longus  instead  of  beneath  them  ;  it  may  pass  oyer  the  extensor  tendons 
of  the  thumb  instead  of  beneath  them.  The  artery  may  be  mistaken 
for  a  radical  of  the  radial  vein.  The  latter  is  superficial,  and  has  like- 
ui-c  other  characteristics  of  a  vein. 


Fig.  155.— Ligature  of  radial  at  apex  of  styloid 
process. 


104-  OPERATIVE   SURGERY. 

R&suMs.—  During  the  late  war  it  was  tied  twenty  times,  with  four 
fatal  results. 

Ligature  of  the  Ulnar  Artery.— This  Yessel  is  larger  than  the 
radial.  It  is  giyen  off  from  the  brachial  about  one  inch  below  the 
bend  of  the  elbow,  passes,  obliquely  inward  and  downward,  deeply  be- 
neath the  superficial  flexors  of  the  forearm,  and  gains  the  ulnar  side  a 
little  aboye  its  middle ;  becoming  superficial,  passes  along  the  outer 
side  of  the  flexor  carpi  ulnaris  to  the  radial  side  of  the  pisiform  bone, 
where  it  terminates  in  the  superficial  palmar  arch.  It  may  be  ligated 
in  three  situations  :  1.  At  the  junction  of  the  upper  and  middle  thirds. 
2.  At  the  lower  third.  3.  At  the  wrist.  It  can  be  ligatured  at  its 
upper  third,  but  such  a  step  has  no  practical  utility  except  when  called 
for  by  a  direct  tying  of  this  portion  of  the  Yessel,  when,  of  course,  as 
in  all  cases,  a  ligature  should  be  applied  at  both  sides  of  the  bleeding 
point. 

The  linear  guide  is  drawn  from  the  extremity  of  the  internal  con- 
dyle to  the  pisiform  bone  (Fig.  150,  c,  cl,  e). 

The  muscular  guide  is  the  outer  border  of  the  flexor  carpi  ulnaris. 

Contiguous  Anatomy. 

Plan  of  Relations  of  the  Ulnar  Artery  is  the  Forearm. 
In  front. 
Superficial  layer  of  flexor  muscles.      ) 
Median  nerve.  [  Upper  half. 

Superficial  and  deep  fasciee,  lower  half. 
Inner  side.  Oilter  side. 

Flexor  carpi  ulnaris.  /  Ulnar  artery  i  Flexor  sublimit  digitorum. 

Ulnar  nerve  (lower  two  thirds).  \    in  forearm.    \ 

Behind. 
Brachialis  anticus. 
Flexor  profundis  digitorum. 

Operation— Junction  of  Middle  and  Upper  Thirds  (Fig.  156). 
— Supinate  the  forearm  and  make  an  incision  about  three  inches  in 


^..^■07 


^iun^r^Slf  ulTart6ry'     FlG-  1^— L^ture  of  ulnar,  function  of  middle 
S,  and    upper  and  upper  thirds.     «.  Flexor  sublimis  digitorum. 

O;  Flexor  carpi  ulnaris.  e.  Sheath  of  artery,  d. 
Ulnar  artery,  e.  Ulnar  nerve.  /.  Venje  comi- 
tes.  J 


LIGATURE   OF  ARTERIES. 


105 


length,  beginning  about  four  finger-breadths  below  the  internal  con- 
dyle, on  the  linear  guide  to  the  vessel  (Fig.  150,  c).  Divide  the  fascia 
on  a  director ;  seek  for  the  line  of  connection 
between  the  borders  of  the  flexor  carpi  ulnaris 
and  the  flexor  sublimis  digitorum.  It  is  of  a 
yellowish-white  color.  Divide  it  on  a  director, 
and  pull  the  muscles  apart,  when  the  ulnar  nerve 
will  be  seen,  to  the  outer  side  of  which  will  be 
found  the  artery  with  its  accompanying  veins  ; 

separate   the  ar- 
^d  tery     and     pass 

the  needle  from 
within  outward 
(Fig.  157). 

Operation  in 
the  Lower  Third 
(Fig.  158).  - 
Place  the  arm  as 

Fig.   159.-Ligature  of  ulnar  artery,  jn  the  prece(Jina 
lower  third,    a.  i  lexor  carpi  ulnaris 
muscle,      b.  Deep  aponeurosis,      c. 
Ulnar  artery,     d.  Venae  comites.     e. 
Ulnar  nerve. 


Fig.  1 58. — Ligature  at  low 
er  third  of  ulnar  artery. 


operation  ;  ex- 
tend the  hand  to 
make  the  tendon 

of  the  flexor  carpi  ulnaris  tense  ;  make  an  incision  about  three 
inches  in  length  along  the  radial  border  of  this  muscle  down  to  the 
fascia  (Fig.  150,  d),  which  should  be  divided  on  a  director,  expos- 
ing the  tendon  of  the  flexor 
carpi  ulnaris,  which  should  be 
drawn  inward,  and  the  artery 
is  seen  beneath  it.  Isolate  the 
vessel  from  its  veins  and  pass 
the  needle  from  within  out- 
ward (Fig.  159). 

Operation  at  the  Wrist 
(Fig.  160).—  Place  the  hand 
on  its  dorsal  surface  and  make 
an  incision  about  two  inches 
in  length  along  the  radial  side  of  the  pisiform  bone,  with  its  con- 
vexity outward  (Fig.  150,  e)  ;  carry  it  downward  along  the  side  of  that 
bone  through  the  fascia  and  fatty  tissue  to  the  vessel.  Flex  the  hand 
and  pass  the  ligature  from  within  outward. 

Fallacies. — Between  the  upper  and  middle  thirds  (150,  c),  the  in- 
terspace between  the  flexor  carpi  ulnaris  and  flexor  sublimis  may  be 
mistaken  for  the  space  between  the  flexor  carpi  ulnaris  and  the  pal- 
maris  kmgns,  or  flexor  carpi  radialis.  If  the  hand  and  linger-  be 
moved  alternately,  the  proper  muscles  can  be  ascertained. 


Fig.  100. — Ligature  of  ulnar  artery  at  wrist. 


106 


OPERATIVE   SURGERY. 


In  the  upper  third  the  vessel  runs  inward  to  meet  its  linear  guide  ; 
therefore  an  attempt  to  find  the  artery  by  the  linear  guide,  in  this  situ- 
ation, will  be  futile.     The  artery  may  run  beneath  the  fascia,  or  oth- 
erwise vary  in  its  course  ;  if  not  in  its 
normal  situation,  deep  pressure  may 
define  it. 

Results. — The  ulnar  artery  was  lig- 
atured during  the  war  ten  times,  with 
three  deaths. 

The  Superficial  Palmar  Arch  can  be 
tied  at  the  seat  of  injury.  It  must  be 
remembered  that  beneath -it  lie  the 
tendons  of  the  flexors  of  the  fingers 
and  the  divisions  of  the  median  and 
ulnar  nerves. 

Linear  Guide  (Fig.  161). — Extend 
the  thumb  at  nearly  a  right  angle  to 
the  carpus,  and  draw  a  line  transverse- 
ly across  it  corresponding  to  its  palmar 
border ;  this  will  denote  the  lower  lim- 
it of  the  arch. 

Operation. — Make  an  incision  half 
or  three  quarters  of  an  inch  in  length 
at  the  seat  of  the  injury,  through  the 
integument,  palmaris  brevis  muscle,  and  palmar  fascia,  down  to  the  ves- 
sel. Ligature  all  bleeding 
points,  and  also  all  un- 
injured branches  arising 
close  to  the  seat  of  the 
injury  of  the  main  vessel, 
to  avoid  the  possibility 
of  secondary  hemorrhage. 
Ligature  of  the  Com- 
mon Carotid  Artery. — 
The  right  common  carot- 
id arises  from  the  innom- 
inate artery,  and  the  left 
from  the  arch  of  the  aorta. 
The  left  is  consequently 
longer  and  more  deeply 
situated  in  the  chest. 
The  left,  after  leaving 
the  aorta,  passes  oblique- 
ly upward  to  a  point  op- 
posite the  left  Stemo-Cla-       Rg.  162._Surgical  anatomy  of  the  common  carotid. 


Fig.  161. — Linear  guide  to  superficial 
arch  and  flexor  tendons. 


LIGATURE   OF   ARTERIES. 


107 


vicular  articulation  ;  and,  from  this  point  upward,  the  right  and  left 
common  carotids  maintain  substantially  the  same  course  to  the  upper 
border  of  the  thyroid  cartilage,  where  each  divides  into  the  internal 
and  external  carotids. 

Each  vessel  may  be  ligatured  in  three  situations  :  1.  At  the  root  of 
the  neck.  2.  Below  the  omo-hyoid  muscle.  3.  Above  the  muscle. 
The  last  two  are  the  situations  commonly  selected,  the  first  not  being 
employed  except  under  forced  circumstances. 

The  linear  guide  to  the  vessel  is  a  line  drawn  from  the  sterno- 
clavicular articulation  to  midway  between  the  angle  of  the  jaw  and 
mastoid  process  (Fig.  136). 

The  muscular  guide  to  the  operation  is  the  anterior  border  of  the 
sterno-cleido-mastoid. 

Contiguous  Anatomy. 


Plan  of  the  Relations  of  the  Common 
In  front. 
Integument  and  fascia. 
Platysma. 
Sterno-mastoid. 
Sterno-hyoid. 
Stcrno-thyroid. 


Externally. 
Internal  jugular  vein. 
Pneumogastiic  nerve. 


Loncrus  colli. 


(  Common 
<   carotid 
(  artery. 


Behind. 


Rectus  capitis  anticus  major. 

Recurrent  laryngeal 


Carotid  Artery.     (Grat.) 

Omo-hyoid. 

Descendens  noni  nerve. 

Sterno-mastoid  artery. 

Superior  thyroid,  lingual,  and  facial 

veins. 
Anterior  jugular  vein. 

Internally. 
Trachea. 
Thyroid  gland. 
Recurrent  laryngeal  nerve. 
Inferior  thyroid  artery. 
Larynx. 
Pharynx. 

Sympathetic  nerve. 
Inferior  thyroid  artery. 


Operation  Mow  the  Omo-hyoid  (Fig.  163).— Place  the  patient  on 
the  back,  with  the  shoulders  slightly  elevated,  and  the  head  turned  to 
the  opposite  side  ;  make  an  incision  three  inches  in  length,  beginning 
a  little  above  the  cricoid  cartilage,  on  the  line  stated,  and  carry  it 
downward  along  the  anterior  border  of  the  sterno-mastoid  (Fig.  136, 
c) ;  divide  the  superficial  fascia,  platysma,  and  deep  fascia  on  a  direct- 
or, thus  exposing  the  anterior  border  of  the  sterno-mastoid  muscle.  If 
the  sterno-mastoid  artery  be  divided,  ligature  it.  If  not  injured,  push 
it  aside,  together  with  the  thyroid  vein  ;  draw  the  sterno-mastoid 
muscle  outward,  and  the  sterno-thyroid  and  hyoid  muscles  inward, 
when  tin-  lower  holder  of  the  omo-hyoid  will  be  seen  above;  divide 
the  fascia  beneath  these  muscles  and  draw  it  apart,  when  the  descend- 
ens noni  nerve  will  he  seen  retting  upon    the  inner  portion  of  the 


108 


OPERATIVE   SURGERY. 


Fig.  163. — Ligature  below  omo-hyoid. 


common  sheath  of  the  carotid,  internal  jugular  vein,  and  the  pneumo- 
gastric  nerve,  the   artery  being  to  the  inner  side,  the  nerve  behind 

and  between  the  two  and 
out  of  sight.  Place  the 
finger  upon  the  sheath, 
to  ascertain  the  exact 
location  of  the  artery  ; 
raise  the  portion  of  the 
sheath,  at  its  inner  side 
corresponding  to  the  site 
of  the  artery,  with  a  te- 
naculum or  the  thumb- 
forceps,  cut  a  small 
opening  into  it,  and  pass 
the  needle  from  without 
inward,  cautiously  in- 
sinuating it  between  the 
vessel  and  its  sheath 
(Fig.  164).  This  ma- 
nipulation should  be  carefully  done,  else  either  the  vein,  pneumogas- 
tric,  or  recurrent  laryngeal  nerves  may  be  injured. 

Operation  above  the  Omo-hyoid. — The  vessel  is  more  superficial  in 
this  situation,  which  is  some- 
times denominated  "  The  site 
of  election"  (Fig.  136,  i). 

Place  the  patient  as  before, 
and  make  an  incision  along 
the  anterior  border  of  the 
sterno-mastoid,  beginning  at 
about  the  angle  of  the  lower 
jaw,  and  extending  it  a  little 
below  the  cricoid  cartilage ; 
divide  the  superficial  fascia, 
platysma,  and  deep  fascia  on  a 
director,  carefully  avoiding  the 
small  veins  ;  expose  the  ante- 
rior border  of  the  sterno-mas- 
toid, and  slightly  flex  the  head 
to  relax  the  tissues  of  the 
neck ;  draw  the  edges  of  the 
wound  apart,  and  the  artery 
will  be  felt  pulsating  in  its 
sheath,  If  the  jugular  vein 
overlap  it,  it  should  be  emp- 
tied by  pressure  above  and  below,  and  be  drawn  outward  ;  then  care- 


Fig.  164. — Ligature  of  the  common  carotid,  a. 
Platysma  myoides  muscle  and  fascia,  b.  Ster- 
no-mastoid, drawn  outward,  c.  Omo-hyoid, 
crossing  the  artery,  d.  Sterno-hyoid  muscle, 
e.  Sterno-thyroid  muscle.  /.  Sheath  of  the 
vessels,  g.  Common  carotid  raised  from  its 
sheath.  h.  Jugular  vein,  pushed  back.  i. 
Pneumogastric"  nerve,  abnormally  prominent. 
j.  Descendens  noni  nerve — sometimes  in  the 
sheath. 


LIGATURE   OF   ARTERIES. 


109 


fully  open  the  sheath  as  before,  avoiding  the  descendens  noni  nerve  ; 
pass  the  needle  carefully  from  without  inward.  It  is  well  to  observe 
the  upper  border  of  the  omo-hyoid  muscle  before  opening  the  sheath, 
that  the  exact  location  to  apply  the  ligature  be  assured. 

Fallacies. — The  artery  may  bifurcate  at  the  cricoid  cartilage,  and 
even  lower ;  however,  this  is  extremely  rare  ;  under  such  circum- 
stances both  branches  should  be  secured.  If  the  vessel  be  pressed 
upon  before  the  ligature  is  tied,  it  will  determine  the  influence  of  the 
ligaturing  upon  the  branches  above. 

The  jugular  vein  may  be  much  dilated,  overlie  and  receive  the  im- 
pulse of  the  artery,  and  therefore  be  mistaken  for  it.  This  fallacy  may 
be  avoided  if  that  vessel  be  emptied  of  its  blood  in  the  manner  before 
described.  The  thyroid  gland  may  be  enlarged  and  obscure  the  ar- 
tery by  displacing  or  overlapping  it.  Under  these  conditions  it  should 
be  pushed  aside.  It  is  reported  that  the  omo-hyoid  muscle  has  been 
mistaken  for  the  artery  ;  the  fact  of  its  being  muscular,  taken  in  con- 
nection with  the  direction  of  its  fibers,  together  with  its  anatomical 
relations,  should  eliminate  any  danger  of  this  mistake.  If  branches 
arise  from  the  main  trunk,  they  may  be  mistaken  for  the  external  caro- 
tid. The  comparative  size  of  the  vessel  and  the  influence  of  pressure 
on  the  circulation  of  the  internal  carotid  will  effectually  solve  the 
question.  If  branches  be  given  off  from  the  common  carotid  near  the 
site  of  the  proposed  ligaturing,  they  should  be  tied  also. 


Fig.  165. — Surgical  anatomy  of  external  carotid. 

Results.—  This  vessel  has  been  tied  seven  hundred  and  eighty-nine 


HO  OPERATIVE   SURGERY. 

times,  for  various  reasons,  of  which  three  hundred  and  twenty-three, 
or  about  forty-one  per  cent,  have  died. 

Ligaturing  of  both  common  carotids,  either  simultaneously  or  at 
variable  intervals,  has  been  done  thirty-six  times.  The  shortest  in- 
terval between  the  operations  in  which  recovery  has  taken  place  is  four 
and  one  half  days.  Instances  where  the  interval  varied  from  thirteen 
to  thirty  days  are  reported,  with  recovery  of  the  patients. 

Ligature  of  the  External  Carotid  Artery.— This  artery  arises  from 
the  common  carotid  at  or  just  above  the  upper  border  of  the  thyroid 
cartilage.  It  ascends  in  a  slightly  curved  course,  with  the  convexity 
forward,  to  a  point  midway  between  the  neck  of  the  condyle  of  the 
lower  jaw  and  the  external  auditory  meatus.  The  upper  part  of  its 
course  lies  in  the  substance  of  the  parotid  gland  (Fig.  165). 

This  artery  may  be  tied  in  two  situations  :  1,  between  the  posterior 
belly  of  the  digastric  and  its  origin  ;  2,  above  the  belly  of  the  digas- 
tric.    The  former  situation  is  the  one  to  be  selected,  if  possible. 

The  linear  and  the  muscular  guides  are  substantially  the  same  as 
for  the  common  carotid. 

Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  External  Carotid.     (Gray.) 
In  front.  Behind. 

Integument,  superficial  fascia.  Superior  laryngeal  nerve. 

Platysma  and  deep  fascia.  c  External )  Stylo-glossus. 

Hypoglossal  nerve.  J    carotid    [         Stylo-pharyngeus. 

Lingual  and  facial  veins.  (    artery.     ;  Glossopharyngeal  nerve. 

Digastric  and  stylo-hyoid  muscles.  Parotid  gland. 

Parotid  gland,  with  facial  nerve  and 
temporo-maxillary  vein  in  its  sub- 
stance. 

Internally. 

Hyoid  bone. 
Pharynx. 
Parotid  gland. 
Ramus  of  jaw. 

Operation  Mow  the  Digastric  Muscle.— -With  the  patient  on  the 
back,  head  slightly  extended  and  turned  to  the  opposite  side,  make 
an  incision  along  the  anterior  border  of  the  sterno-mastoid,  beginning 
opposite  the  angle  of  the  lower  jaw,  .and  carry  it  downward  to  a  point 
nearly  opposite  the  cricoid  cartilage  (Fig.  137,  b).  Divide  the  su- 
perficial fascia,  platysma,  and  deep  fascia  on  a  director  ;  expose  the 
anterior  border  of  the  sterno-mastoid.  The  edges  of  the  wound  should 
be  well  drawn  apart,  when  the  hypoglossal  nerve  and  the  digastric 
and  stylo-hyoid  muscles  will  come  into  view. 

The  end  of  a  grooved  director  should  now  be  employed  to  separate 
and  push  aside  the  lingual  and  facial  veins,  together  with  the  areolar 
tissue  and  lymphatic  glands  that  rest  upon  the  vessel.     Expose  the 


LIGATURE   OF  ARTERIES.  HI 

artery  and  pass  the  ligature  from  without  inward.  The  internal  jugu- 
lar vein  ofttimes  overlaps  the  vessel,  and  should,  be  carefully  drawn 
aside,  or  treated  as  recommended  in  ligaturing  the  common  carotid. 

Before  the  ligature  is  tied  the  following  facts  should  be  carefully 
observed.  :  1.  If  it  be  the  external  carotid  around  which  the  ligature 
is  passed,  this  can  be  ascertained  by  pressing  upon  the  vessel  and  ob- 
serving its  effect  upon  the  circulation  of  the  facial.  2.  The  distance 
of  the  seat  of  the  ligature  from  collateral  branches  ;  this  can  only  be 
determined  by  carefully  exposing  the  vessel  for  half  an  inch  above  and 
below  the  seat  of  the  ligature.  If  vessels  be  found  within  this  extent, 
they  too  should  be  ligatured  to  destroy  the  possibility  of  any  inter- 
ference with  the  formation  of  the  internal  clot.  3.  That  the  ligature 
be  not  carried  around  the  external  and  internal  carotids  at,  or  just 
above,  their  point  of  bifurcation  ;  if  it  be  around  both,  pressure  will 
check  the  pulsation  of  both  ;  if  but  one,  it  will  have  a  like  effect  on 
the  circulation  of  the  vessel  pressed  upon. 

Other  Fallacies. — Enlarged  lymphatic  glands  resting  on  the  vessel 
may  be  mistaken  for  it.  They  need  cause  but  momentary  thought,  since 
their  circumscribed  outline  and  mobility  will  determine  their  nature. 
If  enlarged,  they  should  be  removed,  otherwise  they  can  be  pushed 
aside.  The  superior  thyroid  branch  may  be  confounded  with  the 
lingual.  If  the  course  of  the  respective  vessels  be  observed,  they  can 
be  readily  distinguished  ;  the  superior  thyroid  arises  nearest  the  bifur- 
cation, arches  upward  and  forward,  then  passes  quite  directly  down- 
ward. The  lingual  does  not  arch  downward,  but  passes  upward  and 
inward  to  gain  the  upper  border  of  the  great  cornu  of  the  hyoid  bone, 
which  can  be  easily  outlined  by  the  finger. 

Operation  above  the  Digastric. — Make  an  incision  from  the  lobule 
of  the  ear  to  the  greater  cornu  of  the  hyoid  bone,  along  the  anterior 
border  of  the  sterno-mastoid,  carefully  avoiding  the  parotid  gland. 
Divide  the  superimposed  tissues  as  before,  down  to  the  digastric  mus- 
cle ;  pull  it,  together  with  the  stylo-hyoid,  downward,  and  if  the 
jugular  vein  be  in  the  way,  push  it  outward,  and  pass  the  ligature  from 
without  inward. 

Results. — The  external  carotid  has  been  ligatured  seventy-eight 
times,  with  four  deaths  from  the  operation. 

Ligature  of  the  Internal  Carotid  Artery.— The  internal  carotid  be- 
gins at  the  bifurcation  of  the  common  carotid,  at  or  a  little  above  the 
upper  border  of  the  thyroid  cartilage,  and  passes  perpendicularly  up- 
ward in  front  of  the  transverse  processes  of  the  three  upper  cervical 
vertebra?,  to  the  carotid  foramen  in  the  petrous  portion  of  the  tempo- 
ral bono,  through  which  it  enters  into  the  cranial  cavity.  At  its 
origin  and  in  the  lower  portion  of  its  course  it  lies  externally  and 
posteriorly  to  the  external  carotid  artery.  It  may  be  ligatured  in  any 
part  of  the  course  between  its  origin  and  the  angle  of  the  lower  jaw. 


112 


OPERATIVE   SURGERY. 


The  linear  and  muscular  guides  of  the  external  carotid  artery  are 
suitably  adapted  to  properly  locate  the  internal  carotid. 
Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  Internal  Carotid  Artery  in  the  Neck.     (Gray.) 

In  front. 
Skin,  superficial  and  deep  fasciae. 
Parotid  gland  (above  the  angle  of  the  jaw). 
Stylo-glossus  and  stylo-pharyngeus  muscles. 
Glossopharyngeal  nerve. 

Externally.  Internally. 

Internal  jugular  vein.  Pharynx. 

Pneumogastric  nerve.  j  Internal  carotid  )  Ascending  pharyngeal 

\  artery.  )  artery. 

Tonsil. 
Behind. 

Rectus  capitis  anticus  major. 

Sympathetic. 

Superior  laryngeal  nerve. 

It  may  become  necessary  to  ligature  this  artery  on  account  of  a 
penetrating  wound  received  from  without  or  from  within  the  mouth. 
Ulcerations  of  and  operations  on  the  tonsils  have  been  complicated 
with  injuries  to  this  vessel  that  have  caused  death  from  hemorrhage. 
It  is  therefore  very  important  to  recall  the  relations  of  the  tonsil  and 
pillars  of  the  pharynx  to  this  artery,  in  connection  with  all  injuries 
and  morbid  processes  of  their  structures.  The  angle  of  the  jaw  is  lo- 
cated directly  externally  to  the  tonsil,  and  it  therefore  may  become  a 
practical  guide  to  the  incision  for  ligaturing  the  artery  in  this  situation. 

Operation. — The  position  of  the  neck  of  the  patient  and  the  loca- 
tion of  the  primary  incision  are  similar  to  those  for  the  ligaturing 
of  the  external  carotid.  The  respective  tissues  are  carefully  divided 
on  a  director  down  to  the  muscles,  which  are  then  pulled  aside,  and 
the  ligature  is  passed  from  without  inward,  carefully  avoiding  the 
jugular  vein  and  the  pneumogastric  nerve  at  the  center,  and  the 
pharynx  at  the  inner  side. 

Fallacies. — The  internal  carotid  may  arise  from  the  arch  of  the 
aorta,  and  when  this  occurs  hemorrhage  from  it  can  be  checked  only 
by  ligaturing  the  internal  carotid  itself.  If  but  one  ligature  be  ap- 
plied to  the  internal  carotid  for  hemorrhage,  or  if  the  common  caro- 
tid be  ligatured  alone  for  the  same  reason,  the  collateral  circula- 
tion may  cause  a  continuation  of  the  bleeding.  A  ligaturing  of  the 
internal  carotid  at  both  sides  of  the  bleeding  point  is  the  only  cer- 
tain means  of  arresting  the  hemorrhage  permanently.  The  inter- 
nal carotid  may  lie  internal  to  the  external  carotid.  It  may  be  tor- 
tuous, or  even  be  absent. 

Results. — This  vessel  has  been  tied  alone  three  or  four  times  ;  with 


LIGATURE   OF  ARTERIES.  113 

either  the  common  or  external  carotid,  or  both,  fifteen  times.  Only- 
sis  of  these  patients  died,  and  from  the  causes  calling  for  the  pro- 
cedure. 

Ligature  of  the  Superior  Thyroid  Artery. — This  vessel  comes  from 
the  external,  or  from  the  common  carotid  near  the  point  of  its  bifur- 
cation. It  passes  upward  and  forward,  at  first  quite  superficially, 
then  runs  downward  and  less  superficially  to  enter  the  thyroid  gland. 

Operation. — Make  an  incision  about  three  inches  in  length  along 
the  anterior  border  of  the  sterno-mastoid,  its  center  corresponding  to 
a  point  opposite  the  thyro-hyoid  space.  The  carotid  sheath  should  be 
exposed  as  in  the  ligaturing  of  that  vessel,  and  the  artery  sought  for 
along  its  inner  border. 

Ligature  of  the  Lingual  Artery. — This  vessel  arises  from  the  ex- 
ternal carotid  opposite  the  hyoid  bone,  and  runs  upward  and  inward 
to  about  one  quarter  of  an  inch  above  the  upper  border  of  its  greater 
cornu,  and  passes  horizontally  parallel  with  it,  resting  upon  the  mid- 
dle constrictor  of  the  pharynx,  and  is  covered  first  by  the  digastric 
and  stylo-hyoid  muscles,  and  more  internally  by  the  hyo-glossus.  It 
then  ascends  between  the  hyo-glossus  and  genio-hyo-glossus  muscles 
and  terminates  in  the  ranine  artery. 

It  has  no  superficial  muscular  guide  ;  a  linear  guide  may  be  drawn 
parallel  with,  and  a  fourth  of  an  inch  above,  the  greater  cornu  of  the 
hyoid  bone  (Fig.  136,  a)  ;  practically,  however,  the  upper  border  of 
the  greater  cornu  of  the  hyoid  bone  marks  its  situation.  It  may  be 
ligatured  in  three  situations  :  1.  At  the  apex  of  the  greater  cornu. 
2.  Between  the  cornu  and  the  posterior  belly  of  the  digastric.  3.  In 
the  triangle  made  by  the  digastric  and  mylo-hyoid  muscles,  and  hypo- 
glossal nerve. 

Operation  between  the  Digastric  and  the  Greater  Cornu. — Place  the 
patient  on  the  back,  and  turn  the  head  to  the  opposite  side  ;  carefully 
define  the  greater  cornu  of  the  hyoid  bone.  If  the  neck  be  fleshy,  this 
will  be  somewhat  difficult.  It  can  be  made  more  prominent  on  the 
side  of  the  operation  by  pushing  against  its  body  on  the  opposite  side, 
being  careful  to  press  it  directly  toward  that  point,  otherwise  it  may 
mislead  the  operator.  After  the  patient  is  thoroughly  anaesthetized  to 
prevent  spasmodic  movements  of  the  muscles  attached  to  the  hyoid 
bone,  make  an  incision  about  two  or  three  inches  in  length  parallel 
with  the  upper  border  of  the  cornu,  which  should  pass  down wa rd 
and  outward  to  nearly  the  anterior  border  of  the  sterno-mastoid  (Fig. 
130,  a).  Divide  the  superficial  fascia,  platysma,  and  deep  fascia  on  a 
director;  draw  upward  the  submaxillary  gland  and  divide  the  deep 
aponeurosis,  when  the  digastric  and  stylo-hyoid  muscles  and  the  hypo- 
glossal nerve  will  be  exposed.  Accurately  locate  the  greater  cornu 
with  the  finger  and  fix  it  with  a  tenaculum,  draw  up  the  digastric  and 
the  stylo-hyoid  muscles  and  hypoglossal  nerve  with  a  blnnt  hook,  push 

8 


114 


OPERATIVE   SURGERY. 


aside  the  lingual  vein  if  seen,  and  pick  up  the  fibers  of  the  hyo-glossus 
with  a  pair  of  forceps,  and  incise  them  in  the  direction  of  the  external 
incision  about  one  quarter  of  an  inch  above  the  greater  co.nu  ;  beneath 

,      them  will  be  found  the 
.  ,"i  \    vessel,  sometimes  accom- 
"ay     panied   by    the   lingual 
\   vein  (Fig.   166).      Pass 
J    the  needle  from  the  vein. 
W     Before  tying  the  liga- 
ture, ascertain  if  pres- 
sure will  stop  the  pulsa- 
tion of  the  artery. 

Ligature  in  the 
Third  Situation. — This 
is  often  called  "  the 
place  of  election."  Make 
an  incision  transversely 
two  inches  long,  con- 
cavity upward,  and  its 
center  just  within  the 
middle  of  the  cornu  of  the  hyoid  bone.  Divide  the  integument,  su- 
perficial fascia,  and  platysma,  carefully  avoiding  the  superficial  veins ; 


/* 


Fig.  166. — Ligature  of  lingual  artery. 


Fig.  167.— Surgical  anatomy  of  the  lingual  artery.  1.  Submaxillary  gland.  2.  Lingual 
artery.  3.  Lingual  vein.  4.  Hypoglossal  nerve.  5.  Stylo-hyoid  muscle.  6.  Digastric 
muscle.     1.  Mylo-hyoid  muscle.     8.  Hyoid  bone.     9.  Hyo-glossus  muscle. 

divide  the  deep  fascia  and  pull  upward  the  submaxillary  gland,  when 
the  posterior  belly  of  the  digastric  will  come  into  view,  as  also  the 
posterior  border  of  the  stylo-hyoid  muscle  and  the  hypoglossal  nerve, 
accompanied  usually  by  the  lingual  vein.  Carefully  outline  the  trian- 
gle before  mentioned,  pinch  up  the  fibers  of  the  hyo-glossus,  and  divide 
them  midway  between  the  hyoid  bone  and  the  nerve,  when  the  artery 


LIGATURE   OF  ARTERIES.  115 

will  be  seen  beneath  (Fig.  167).  Separate  it  from  the  vein,  if  the  vein 
lie  beneath  the  muscle  and  has  not  been  seen  before,  and  pass  the  liga- 
ture. 

Ligature  in  the  First  Portion. — In  this  situation  the  vessel  is  tied 
between  the  point  of  its  giving  off  and  the  tip  of  the  greater  cornu  of 
the  hyoid  bone. 

Operation. — Make  an  incision  three  inches  in  length  running  ob- 
liquely downward  and  backward,  its  center  corresponding  to  the  greater 
cornu.  The  various  tissues  are  carefully  divided  as  before,  and  the 
hypoglossal  nerve  is  exposed.  The  numerous  veins  located  in  the 
course  are  now  pushed  aside,  and  the  artery  carefully  sought  for  at  the 
point  of  the  cornu,  and  ligatured.  This  operation,  on  account  of  the 
absence  of  a  definite  deep  guide  to  the  location  of  the  vessel,  and  the 
uncertainty  of  its  point  of  origin,  together  with  the  great  number  of 
large  veins  in  the  course  of  the  search,  is  much  less  feasible  than  either 
of  the  other  two. 

Fallacies. — The  hypoglossal  nerve  may  be  mistaken  for  the  artery. 
The  nerve  rests  on  the  hyo-glossus  ;  the  artery  runs  beneath  it.  This, 
together  with  the  pulsation  of  the  artery  and  other  distinctive  ana- 
tomical features,  should  render  the  discrimination  easy.  It  is  well  to 
know,  however,  that  the  movements  of  the  tissues  dependent  on  the 
acts  of  respiration  make  it  somewhat  difficult,  and  often  impossible,  to 
detect  the  arterial  impulse.  If,  however,  the  supposed  artery  be  care- 
fully isolated,  the  ligature  passed  around  it,  and  a  good  light  thrown 
into  the  wound,  its  tortuous  outline  will  be  noticed  with  each  pulsa- 
tion. The  pulsation  can  be  seen  best  in  the  interval  of  the  respiratory 
acts,  when  the  tissues  are  quiet. 

The  lingual  vein  may  be  mistaken  for  the  artery.  This  vessel 
sometimes  runs  with  the  artery  behind  the  hyo-glossus;  more  fre- 
quently, however,  it  rests  on  this  muscle.  It  has  the  characteristic 
color  of  a  vein,  and  is  larger  than  the  artery.  The  lingual  artery 
may  be  absent  on  one  side.  After  the  division  of  the  fibers  of  the 
hyo-glossus,  the  search  for  the  vessel  must  be  conducted  cautiously 
to  avoid  opening  into  the  pharynx. 

Results. — It  has  been  tied  repeatedly  with  great  advantage,  for  the 
purpose  of  controlling  hemorrhage  from  the  tongue,  and  delaying  a 
morbid  growth  of  the  same. 

Ligature  of  the  Facial  Artery. — The  facial  is  one  of  the  large 
branches  of  the  external  carotid.  It  arises  from  it  just  above  the  tip 
of  the  greater  cornu,  or  about  one  inch  from  the  bifurcation  of  the 
common  carotid,  passes  forward  and  upward  beneath  the  ramus  of  the 
lower  jaw,  going  through  the  substance  of  the  submaxillary  gland, 
and  gains  the  external  surface  of  the  ramus  at  the  anterior  inferior 
angle  of  the  masseter  muscle,  lying  in  a  groove  in  the  outer  border  of 
the  bone.      The    masseter    muscle,   therefore,  becomes  Us  muscular 


116 


OPERATIVE  SURGERY. 


guide  in  a  portion  of  its  course.  It  may  be  ligatured  in  two  situa- 
tions :  in  the  neck,  and  as  it  crosses  the  ramus  of  the  jaw,  the  latter 
being  the  better.  In  the  former,  the  head  is  turned  to  the  opposite 
side,  and  an  incision  of  about  three  inches  in  length  is  made  obliquely 
downward  and  forward  a  little  in  front  of  the  anterior  border  of  the 
sterno-mastoid,  its  center  being  at  a  point  about  one  third  of  an  inch 
above  the  tip  of  the  greater  cornu.  The  dissection  is  carefully  made 
as  in  ligaturing  the  lingual  at  this  first  portion,  pushing  aside  the 
facial  and  other  contiguous  veins,  drawing  up  the  digastric  and  pass- 
ing the  ligature. 

Operation  at  the  Ramus  of  the  Jaw. — Place  the  patient  as  before, 
draw  the  skin  upward  over  the  ramus,  so  that  when  retraction  of  the 
tissues  occurs  the  cicatrix  will  be  beneath  the  jaw  ;  make  an  incision 
about  two  inches  in  length  along  the  border  of  the  jaw,  divide  the 
tissues  on  a  director  (Fig.  137,  c),  down  to  the  vessel ;  isolate  it,  and 
pass  the  ligature.  If  a  resulting  cicatrix  be  of  no  moment,  the  pri- 
mary incision  can  be 
made  in  the  long  axis  of 
the  vessel  along  the  an- 
terior border  of  the  mas- 
seter  muscle  (Fig.  168). 
Fallacies. — At  its  or- 
igin this  vessel  may  be 
mistaken  for  the  lingual. 
Interruption  of  the  cir- 
culation will  easily  deter- 
mine the  difference. 

Ligature  of  the  Tem- 
poral Artery. — The  tem- 
poral is  one  of  the  term- 
inal branches  of  the  ex- 
ternal carotid.  It  begins 
in  the  substance  of  the 
parotid  gland  between 
the  neck  of  the  lower  jaw  and  the  external  meatus  and  passes  upward 
across  the  root  of  the  zygoma,  subcutaneously,  where  its  pulsation  can 
be  distinctly  felt.  About  two  inches  above  the  zygomatic  process  it 
divides  into  its  terminal  branches. 

The  zygomatic  process  is  the  bony  guide  to  it. 
Operation  (Fig.  137,  d).—  Make  an  incision  in  the  line  of  the  ves- 
sel, as  indicated  by  its  pulsation,  about  one  fourth  of  an  inch  in  front 
of  the  tragus  and  one  inch  in  length ;  divide  the  skin  and  fascia ; 
expose  the  vessel  and  pass  the  needle  so  as  to  avoid  the  vein  and 
nerve  (Fig.  168). 

The  Ligature  of  the  Occipital  Artery.— This  artery  arises  from  the 


Fig.  168. — Ligature  of  facial  and  temporal  arteries. 


OPERATIONS   ON   VEINS,   CAPILLARIES,   ETC. 


117 


external  carotid  a  trifle  above  the  facial,  and  passes  upward  and  out- 
ward to  the  interval  between  the  transverse  process  of  the  atlas  and 
the  mastoid  process  of  the  occipital  bone.-  It  then  passes  over  the 
posterior  portion  of  the  skull  midway 
between  the  external  occipital  pro- 
tuberance and  the  mastoid  process 
(Fig.  137,  e).  It  has  no  muscular 
guide.  It  may  be  tied  at  its  origin 
or  behind  the  mastoid  process. 

Operation  at  its  Origin. — Make 
an  incision  along  the  inner  border  of 
the  sterno-mastoid,  about  three  inch- 
es in  length,  its  center  correspond- 
ing to  a  point  a  little  above  the  apex 
of  the  greater  cornu  of  the  hyoid 
bone.  Divide  the  superficial  tissues 
carefully  on  a  director  ;  separate  the 
areolar  tissue  with  its  blunt  extrem- 
ity ;  push  aside  the  veins  and  find 
the  posterior  belly  of  the  digastric.  A  little  below  this  will  be  seen 
the  ninth  pair  of  nerves,  winding  around  the  object  of  search.  Pass 
the  needle  from  the  nerve. 

Operation  behind  the  Mastoid  Process  (Fig.  169). — Make  an  incision 
about  two  inches  in  length  one-half  inch  behind  and  a  little  below  the 
mastoid  process.  Divide  the  integument  and  attachments  of  the 
sterno-mastoid  and  the  splenitis  muscles ;  feel  for  the  pulsation  at  the 
bottom  of  the  wound.     Isolate  the  artery  and  pass  the  ligature. 


Fig.  169. — Ligature  of  occipital  artery. 


CIIAPTEE  V. 


OPERATIONS   ON    VEINS,    CAPILLARIES,  ETC. 

Ligature  of  Veins. — Veins,  like  arteries,  may  be  ligatured  in  their 
continuity  or  at  their  divided  extremities.  Large  venous  branches, 
when  divided  in  the  course  of  an  operation,  should  always  be  tied, 
otherwise  they  may  give  rise  to  an  objectionable  amount  of  oozing, 
which  will  interfere  with  the  rapidity  of  the  union  of  the  divided  sur- 
faces, and  possibly  require  the  re-opening  of  the  wound  to  secure  the 
bleeding  point-.  If  a  large  vein  be  nicked  during  an  operation — as  the 
interna]  jugular,  during  the  removal  of  growths  from  the  neck — liga- 
tures may  be  thrown  around  it,  above  and   below  the  opening,  rather 


11Q  OPERATIVE   SURGERY. 

than  to  tie  the  nicked  portion.  The  latter  procedure  is  liable  to  be 
followed  by  secondary  hemorrhage.  The  practice  of  ligaturing  the 
opening,  or  of  sewing  its  divided  borders  by  fine. catgut,  is  highly 
extolled  by  many  writers.  If  it  be  determined  to  tie  the  vessel,  it 
should  be  done  above  and  below  the  wound  of  the  vessel,  else  the  re- 
turn circulation  will  cause  secondary  hemorrhage.  If  it  be  possible 
at  the  onset  to  surround  the  patient  with  the  degree  of  surveillance 
necessary  to  detect  and  treat  secondary  hemorrhage,  I  am  of  the  opin- 
ion that  the  practice  of  sewing  the  nick  with  the  continuous  or  other 
suitable  form  of  suture — such  as  is  used  for  intestinal  wounds — offers 
the  better  opportunity  for  rapid  recovery.  Aside  from  the  ligaturing  of 
veins  on  account  of  traumatism,  they  are  ligatured  in  their  continuity 
for  the  purpose  of  causing  their  occlusion  in  those  cases  in  which  they 
are  in  a  dilated  or  varicose  condition. 

Operations  for  Varicose  Veins. — When  the  veins  of  the  lower  ex- 
tremities become  too  much  distended  to  be  amenable  to  palliative 
measures,  it  is  often  necessary  to  resort  to  operative  interference, 
which  has  for  its  object  the  occlusion  of  the  distended  canals.  Injec- 
tion, acupressure,  and  ligaturing  are  the  common  means  employed. 

Injection. — The  vein  is  compressed  by  the  fingers  above  and  below 
the  proposed  point  of  injection — leaving  an  intervening  space  of  an 
inch  or  less — or  by  small  pads  confined  in  position  with  adhesive  plas- 
ter, the  latter  being  the  better  plan.  Into  the  isolated  portion  twenty 
or  thirty  drops  of  a  twenty-per-cent  solution  of  liquor  ferri  subsul- 
phatis  and  water  are  then  slowly  injected.  Almost  immediately  the 
contents  of  the  vessel  become  coagulated,  when  the  pressure  can  be 
removed.  The  limb  should  be  kept  quiet  for  a  few  days,  and  any 
tendency  to  undue  inflammation  combated. 

The  results  of  this  operation,  while  not  so  favorable  as  other  expe- 
dients, are,  nevertheless,  very  satisfactory.  Of  the  one  hundred  and 
three  cases  some  time  since  reported,  seventy-nine  were  cured,  one 
died,  and  of  the  remainder,  sixteen  were  failures. 

Acupressure. — This  is  substantially  the  same  as  the  application  of 
acupressure  for  arresting  the  circulation  of  arterial  trunks.  It  con- 
sists simply  of  carrying  thoroughly  purified  needles  or  pins,  which 
may  or  may  not  have  been  constructed  for  the  purpose,  beneath  the 
vein  at  intervals  of  an  inch  or  so,  and  compressing  the  superimposed 
tissues  by  means  of  carbolized  silk  or  cotton  yarn  wound  over  the 
protruding  ends  of  the  pins.  The  pins  are  removed  on  the  sixth  or 
seventh  day,  depending  on  the  degree  of  ulceration  produced.  Cau- 
tion should  be  observed  that  the  pins  be  not  passed  through  instead 
of  beneath  the  vein,  otherwise  a  serious  phlebitis  may  follow. 

Subcutaneous  Ligaturing. — This  is  accomplished  by  passing  a  car- 
bolized needle,  armed  with  a  fine  wire  or  a  catgut  ligature,  in  front  of 
and  across  the  vein,  after  which  the  direction  is  changed  so  as  to 


OPERATIONS   OX   VEINS,   CAPILLARIES,   ETC.  H9 

carry  it  beneath  the  vessel  and  out  at  the  point  of  entrance.  If  wire 
be  used  it  is  then  twisted  and  cut  short,  and  tbe  opening  closed  anti- 
septically.  Should  catgut  be  employed,  it  is  tied,  and  cut,  and  the 
opening  treated  in  the  same  manner.  Three  or  four  of  these  constric- 
tions may  be  applied  at  intervals  of  an  inch.  If  the  blood  in  the  in- 
tervening spaces  becomes  necrosed,  giving  rise  to  fluctuation,  it  should 
be  evacuated,  as  absorption  is  then  impossible.  In  the  subcutaneous 
ligaturing  of  varicose  veins — such  as  the  long  and  short  saphenous 
veins — that  are  accompanied  by  nerves,  the  nerves  may  be  accident- 
ally included  by  the  ligature.  It  is  safer,  in  such  instances,  to  ex- 
pose the  vein  and  pass  the  ligatures,  as  in  arterial  ligaturing,  after 
which  the  included  portion  of  the  vein  can  be  excised,  or  simply 
divided.     Thorough  antisepsis  should  be  practiced  in  such  cases. 

Hemorrhoids. —  A  varicose  condition  of  the  hemorrhoidal  veins 
causes  a  disease  denominated  hemorrhoids  or  piles,  for  the  cure  of 
which  various  radical  measures  are  recommended.  The  patient  is 
prepared  by  a  saline  cathartic,  which  should  be  followed  by  an  enema, 
a  few  hours  prior  to  the  operation.  He  should  then  be  etherized, 
placed  upon  a  table  of  suitable  height,  with  the  buttocks  drawn  down 
to  the  edge  ;  the  thighs  are  then  elevated,  drawn  apart,  and  the  nates 
separated.  If  the  growths  be  of  the  external  variety,  and  not  inflamed, 
they  can  be  nipped  off  with  a  pair  of  scissors,  being  careful  not  to  cut 
them  too  closely,  else  the  resulting  cicatrization  may  cause  a  narrow- 
ing of  the  anal  orifice.  Local  anaesthesia  is  sufficient  to  overcome  the 
pain  attending  this  operation.  If  the  hemorrhoid  be  distended,  ten- 
der, and  painful,  it  is  generally  necessary  to  employ  general  anaesthe- 
sia. The  tumor  should  be  taken  between  the  thumb  and  finger,  raised 
up,  drawn  out,  transfixed  near  the  base,  and  cut  outward  ;  gentle 
pressure  will  then  evacuate  its  contents,  after  which  a  pellet  of  fine 
oakum  saturated  with  balsam  of  Peru,  marine  lint,  or  iodoform  gauze, 
should  be  placed  in  the  bottom  of  the  sack,  and  the  operation  is  com- 
pleted. To  facilitate  union,  the  transfixing  incision  is  made  in  the 
direction  of  the  radiating  folds  of  the  anus. 

Operations  for  Internal  Hemorrhoids.— These  are  quite  numerous, 
but  the  following  are  believed  to  secure  the  best  results  : 

Excision. — This  method  is  reckoned  among  those  which  secure  the 
best  results  in  selected  cases.  It  causes  little  after-pain,  and  recovery 
takes  place  within  a  week  or  ten  days.  It  is  applicable  to  those  cases 
where  but  three  or  four  tumors  exist,  which  are  not  very  large,  and 
have  well-defined  bases.  The  sphincter  should  be  well  dilated  and  the 
anus  opened  with  a  speculum  or  retractor.  The  pile  is  then  seized  at 
the  base  with  a  rolsella,  and  cut  off  with  a  pair  of  scissors  above  the 
point  grasped,  which  should  be  held  till  all  arterial  hemorrhage  is 
stopped  by  twisting  the  bleeding  points.  After  it  has  ceased,  pledgets 
of  lint  saturated  with  tannin  and  water,  or  with   liquor  ferri  subsul- 


120 


OPERATIVE  SURGERY. 


phatis,  are  applied  to  the  cut  surfaces,  and  the  patient  kept  quiet  for 
twenty-four  to  forty-eight  hours. 

Results.—  This  method  of  operating  has  been  frequently  per- 
formed, and  with  eminent  success. 

Crushing.— -This  method  consists  in  crushing  the  pedicle  of  the 

growth  by  an 
improvised  in- 
strument or  one 
especially  con- 
structed for 
that  purpose 
(Fig.  170).  It 
is  not  suitable 
for  universal 
application,  but 

rather  to  those 
Fig.  170.— Allingham's  screw  crushing  instrument  for  hemorrhoids.  ^umors     which 

possess  well-defined  bases.  The  integument,  if  it  be  connected  with 
the  tumor,  should  be  incised,  otherwise  too  great  pain  will  be  caused. 

Operation. — The  patient  being  prepared  as  in  the  preceding  in- 
stance, the  pile  is  pulled  between  the  bars  of  the  instrument  by  the 
aid  of  a  hook  or  a  volsella,  after  which  the  screw  is  turned  tightly 
against  it.  The  projecting  portion  is  then  cut  off.  The  instrument 
is  retained  in  position  for  half  a  minute  or  so,  to  insure  against  the 
danger  of  hemorrhage.  While  this  method  may  be  classed  among  the 
satisfactory  ones,  it  possesses  no  superiority  over  the  treatment  by 
ligature,  and  as  a  rule  causes  more  pain,  less  speedy  recovery,  and 
exposes  the  patient  to  the  possible  danger  of  subsequent  hemorrhage. 

Ligaturing. — This  method  may  be  employed  with  or  without  in- 
cision, the  latter  being  preferable.  The  treatment  without  incision  is 
to  pass  a  needle,  armed  with  a  double  ligature  of  stout  carbolized  silk 
or  catgut,  through  the  base  of  the  growth,  tying  each  half  separately, 
after  which  the  pile  is  cut  off  below  the  ligature.  If  strong  catgut  be 
used,  the  ends  should  be  divided  close  to  the  pedicle,  while  with  silk, 
one  end  may  be  allowed  to  hang  from  the  anus. 

Ligature  ivith  inciSion  consists  in  drawing  down  the  tumors  by 
aid  of  forceps  or  volsella  to  the  anus,  or  beyond  it,  and  with  a  pair  of 
curved  scissors  dividing  them  from  their  connection  with  the  sub- 
mucous membrane  from  below  upward,  parallel  with  the  bowel,  far 
enough  to  leave  the  pile  connected  only  by  a  slim  pedicle,  around 
which  a  strong  ligature  should  be  cast  and  securely  tied.  The  liga- 
tured portion  is  then  cut  off  and  the  parts  returned.  The  vessels 
connected  with  the  growth  enter  it  from  above  downward,  parallel 
with  the  gut,  and  are  therefore  secure  from  injury,  if  ordinary  caution 
be  observed. 


OPERATIONS   ON  VEINS,  CAPILLARIES,   ETC. 


121 


Injection. — The  injection  of  carbolic  acid  and  astringent  agents, 
together  with  the  application  of  caustics,  is  hardly  entitled  to  the  dig- 
nity of  being  considered  an  operation.  Nor  are  the  results,  notwith- 
standing the  claims  of  some  to  the  contrary,  on  the  whole  better  than 
bv  ligature,  either  with  or  without  incision.  The  occasional  severe 
inflammatory  reaction,  often  followed  by  abscesses  and  gangrene,  de- 
tract from  that  which  might  otherwise  become  an  extremely  satisfac- 
tory remedy.  The  full  explanation  of  these  methods  cau  be  found  in 
systematic  treatises  upon  the  subject. 

Varicocele. — This  is  caused  by  a  varicose  condition  of  the  spermatic 
veins  (Fig.  171).     The  treatment  of  the  varicose  veins  of  the  cord, 

like  that  for  varicose  veins  in  other  sit- 
uations, is  divided  into  the  palliative 
and  radical  methods,  the  object  of  the 
latter  being  to  obliterate  the  lumen  of 
the  vessels.  The  same  dangers  apper- 
tain to  operations  upon  these  veins  as 
upon  those  of  other  portions  of  the  ve- 
nous system.  Erysipelas,  phlebitis,  pyae- 
mia, to  which  may  be  added  a  conse- 
quent atrophy  of  the  testicle  depending 
upon  the  occlusion  of  the  vein  or  arte- 
ry, may  follow  ;  therefore,  radical  mea- 


^Ss^^' 


Fig.  171. — Varicose  spermatic  veins. 


Fig.  172. — Morgan's  suspensory. 


sures  directed  to  the  vessels  should  not  be  entertained,  except  in  old 
age,  until  the  disease  becomes  a  source  of  discomfort  and  even  dis- 
tress. The  palliative  treatment  consists  in  shortening  the  cord  by 
raising  the  scrotum  and  its  contents,  which  lessens  the  weiglai  of  the 
column  of  blood  contained  in  the  vessels.  This  is  achieved  by  the 
various  forma  of  suspensories,  as  Morgan's  (Kg.  172),  or  the  one  in 
ordinary  ose.  Should  these  serve  to  relieve  the  urgent  symptoms,  the 
patient  may  not  deem  it  desirable  to  submit  to  an  operation  of  any 
kind,     if,   however,  the  characteristic  symptoms  recur  or  continue, 


122 


OPERATIVE  SURGERY. 


then  the  palliative  operation  for  shortening  the  scrotum  should  be 
made. 

Excision  of  the  Scrotum.— The  instruments  required  for  this  sim- 
ple operation  are  the  scrotal  clamp— the  one  devised  by  Dr.  Henry 
being  in   every  way  suitable  (Fig.   173)— a  sharp  bistoury,  needles 

armed  with  silver  wire  or  carbolized  silk, 
artery  forceps,  and  catgut  ligatures.  The 
scrotum  should  be  thoroughly  cleansed 
and  the  patient  anaesthetized  ;  the  clamp 
is  then  applied  to  the  side  afflicted  by 
drawing  the  bottom  of  the  scrotum  be- 
tween the  blades,  which  should  be  applied 
as  nearly  as  possible  parallel  with  the 
raphe  ;  all  danger  of  including  the  testi- 
cle is  obviated  by-  pressing  it  upward  to 
the  external  abdominal  ring.  When  a 
sufficient  amount  of  tissue  is  grasped  to 
meet  the  indication,  the  blades  are  tight- 
ened to  cut  off  all  circulation,  at  the  same 
time  to  securely  hold  the  scrotal  tissue  ; 
the  protruding  portion  is  then  transfixed, 
on  a  level  with  the  adjustable  bar  (Fig.  173, 
a),  by  a  sharp,  narrow-bladed  bistoury, 
and  cut  off.  Before  the  blades  are  loos- 
ened it  is  better  to  pass  the  sutures,  which 
should  be  at  least  ten  inches  in  length, 
through  the  divided  borders.  Having  ad- 
justed them,  remove  the  clamp,  tie  the 
bleeding  points,  and  close  the  wound. 
Care  must  always  be  taken  to  stop  all 

\B11||^  bleeding  points  before  the  edges  of  the 

Ifikllk  wound  are  united  ;   else,  owing  to  the 

looseness  of  the  scrotal  tissues,  an  ordinary 
oozing  may  cause  the  formation  of  large 
bloody  clots,  which  must  be  removed.  If 
a  drainage-tube  be  introduced  throughout  its  course  and  allowed  to 
protrude  at  its  most  dependent  extremity,  this  danger  will  be  further 
avoided.  Place  the  patient  in  bed,  elevate  the  scrotum,  and  dress  the 
wound  antiseptically.  It  usually  heals  quickly,  and  affords  sufficient 
relief  to  amply  recompense  the  patient  for  the  annoyance  incurred 
from  the  operation.  If  the  instrument  just  described  be  not  at  hand, 
the  operation  should  not  be  rejected  for  this  reason.  A  clamp  of 
practical  utility  may  be  extemporized  from  long-handled  forceps,  or  by 
adjusting  to  the  scrotum  two  narrow  bars  of  metal  or  stiff  wood,  the 
extremities  of  which  can  be  firmly  held  by  the  hands  of  an  assistant. 


Fig.  173. — Ilenry's  scrotal  clamp. 


OPERATIONS   ON    VEINS,    CAPILLARIES,    ETC. 


123 


Radical  Treatment  for  Varicocele. — The  means  employed  to  ob- 
literate the  dilated  vessels  are  quite  numerous.  They  all,  however, 
accomplish  the  result  by  compression.  Only  such  as  are  considered 
practically  consistent  with  the  safety  of  the  patient  are  here  described. 
In  all  the  operations  great  care  must  be  exercised  to  avoid  the  vas 
deferens  and  artery.  They  lie  posteriorly  to  the  enlarged  and  worm- 
like congeries  of  vessels,  around  which  the  compression  is  to  be  ap- 
plied. If  the  patient  be  caused  to  lie  down  with  the  hips  elevated,  the 
blood  will  return  from  the  varicose  veins  into  the  general  circulation, 
after  which  the  vas  deferens  and  the  artery  can  be  easily  isolated  and 
separated  from  the  veins.  If  the  patient  then  assume  an  erect  posi- 
tion the  veins  will  again  become  distended,  when,  if  pressure  be  main- 
tained upon  the  cord  at  the  external  ring,  the  vessels  can  be  distinctly 
outlined  if  the  patient  be  again  placed  in  the  recumbent  position.  The 
operator  having  thus  carefully  located  the  vas  deferens  and  the  artery, 
the  patient  can  be  etherized  and  the  operations  proceeded  with. 

Compression  by  Plus  (Fig.  174). — This  consists  simply  of  passing 


Pig.  174. — Occlusion 
by  pins. 


Fig.  175. — Wires  in 
position.     (Videl'fl 

operation.) 


FlG.  176. — Wires  Fig.  177. — Vessels 
twisted.  (Videl's  occluded.  (Videl's 
operation.)  operation.) 


a  strong  pin  through  the  scrotal  tissues  in  front  of  the  vas  deferens 
and  the  artery,  and  throwing  around  its  protruding  extremities  an 
elastic  ligature,  or  cotton  yarn,  drawn  sufficiently  tight  to  cut  off  the 
circulation.  This  procedure  should  be  repeated  at  about  one  inch 
from  the  6rs<  application.  The  pins  can  be  withdrawn  at  the  end  of 
three  or  four  days. 

Compression  by  Wires  (Videl's). — This  is  done  by  passing  a  stout 

wire  either  in  front  of  or  behind  the  veins,  preferably  the  latter,  then 

passing  a  second  but  smaller.one  at  the  opposite  side,  but  through  the 
same  opening  in  the  integumenl  (Fig.  175).  They  are  then  twisted 
together  till  the  veins  are  thoroughly  compressed  and  rolled  around 
them  (Figs.  176  and  L77). 

Subcutaneous   Ligaturing.     This  is  accomplished  by  carrying  a 


124 


OPERATIVE   SURGERY. 


needle  armed  with  a  silver  wire  between  the  veins  and  the  remaining 
vessels  of  the  cord,  returning  it  at  the  point  of  entrance,  going  in 
front  of  the  veins.     The  wire  is  then  twisted  firmly.     A  strong  silk 

ligature  can  be  applied  in 
a  similar  manner.  The 
amount  of  tissue  in  their 
grasp  renders  the  separa- 
tion somewhat  tedious. 
The  process  of  separa- 
tion can  be  hastened  by 
tying  the  ligature  over 
a  small  cylinder  of  elas- 
tic tubing  (Levis),  the 
resistancy  of  which  will 
exercise  a  constant  trac- 
tion (Fig.  178).  If  this 
be  done,  a  button  should 
be  introduced  between 
the  tissues  and  tubing  to  protect  the  skin  (Pancoast). 

Strong  catgut  ligatures,  or  antiseptic  silk,  can  be  carried  around 
the  dilated  veins,  an  inch  or  so  apart,  by  means  of  an  ordinary  needle 
— or  by  an  instrument  especially  devised  for  the  purpose — and  caused 
to  emerge  at  the  point  of  entrance,  tied,  ends  cut  short,  and  permitted 
to  remain  until  they  are  absorbed.  The  veins  may  be  divided  subcu- 
taneously  between  the  ligatures  after  they  have  been  tied. 

The  expedient  advised  by  Prof.  E.  L.  Keyes  for  passing  the  liga- 
tures is  not  only  ingenious  but  also  simple.  A  needle  with  a  fixed 
handle,  having  two  eyes  at  its  point  (Fig.  179),  is  armed  with  two 
antiseptic  ligatures — one  carried  through  each  eye.     The  ends  of  the 


Fig.  178. — Elastic  traction. 


Fig.  179. — Keyes'  needle. 

posterior  ligature  are  tied  to  form  a  loop  ;  the  anterior  ligature  is 
permitted  to  hang  loosely,  with  an  equal  portion  at  each  side  of 
the  needle.  The  enlarged  veins  are  isolated,  and  the  point  of  the 
needle  is  pushed  through  the  scrotal  tissues  in  close  contact  with 
their  posterior  surfaces.  One  end  of  the  untied  ligature  is  then 
drawn  through  the  tissues  with  forceps,  and  caused  to  remain  in  this 
position,  while  the  needle  is  withdrawn  sufficiently  to  permit  its 
point  to  be  carried  in  front  of  the  distended  veins,  out  through  the 
original  point  of  exit,  when  the  distal  end  of  the  untied  ligature  is 
passed  through  the  advanced  portion  of  the  looped  one  and  drawn 
by  it  through  the  point  of  entrance   to    the  scrotal   tissues   by   the 


OPERATIONS   ON  VEINS,   CAPILLARIES,   ETC. 


125 


Fig.  180. — Ricord's  loops. 


complete  withdrawal  of  the  needle.  The  deposited  ligature  is  then 
freed  from  the  scrotal  tissues  by  making  one  or  two  sharp  pulls  upon 
it,  tied  firmly  around  the  veins,  its  extremities  cut  short  and  allowed 
to  disappear  within  the  scrotum.  If  thorough  antiseptic  precautions 
be  observed,  the  ligatures  will  rarely  cause  subsequent  local  trouble. 

The  Double-Loop  Compression  of  Ricord  (Fig.  180). — This  is  an 
excellent  plan,  and  can  be  readily  exe- 
cuted by  passing  a  needle  armed  with  a 
silk  ligature  between  the  veins  and  the 
vas  deferens  ;  to  this  is  fastened  a  double 
ligature,  which  is  drawn  through  and  left 
in  position.  The  needle  with  its  silk 
ligature  is  then  passed  in  front  of  the  veins 
in  the  opposite  direction,  entering  and  emerging  at  the  points  pre- 
viously made.  A  second  double  ligature  is  then  drawn  through  and 
left  in  position.  The  extremities  on  the  respective  sides  are  now 
tucked  through  the  loops  on  the  same  side  and  drawn  tight,  and  tied 
over  a  narrow  roller  or  piece  of  elastic  tubing.  The  ligatures  will  cut 
their  way  through  in  five  or  six  days.  The  methods  of  cure  by  ex- 
posure, division,  and  ex- 
cision of  the  vessels  are 
more  dangerous,  and 
have  infrequently  re- 
sulted in  death  from 
pyaemia. 

Venesection. —  While 
the  withdrawing  of  blood 
from  a  vein  can  hardly 
be  classed  as  an  operation 
of  much  moment  in  a 
surgical  sense,  yet  the 
infrequency  of  its  em- 
ployment at  the  present 
time  is  quite  apt  to  ren- 
der the  details  connected 
therewith  somewhat  un- 
certain in  the  minds  of  a 
majority  of  the  practi- 
tioners of  the  present 
generation.  The  veins 
selected  for  the  proce- 
dure are  the  internal 
saphenous  at  the  ankle, 
the  median  basilic,  or  median  cephalic  at  the  bend  of  the  elbow,  and 
external  jugular  in  the  neck.      The  instruments  required  arc  the  or- 


Tvi.  181. — Opening  the  vein  with  scalpel. 


126 


OPERATIVE  SURGERY. 


dinary  thumb-lancet,  or  a  curved  or  straight  sharp-pointed  bistoury  ; 
the  first,  however,  possesses  the  greater  number  of  traditional  virtues. 
Should  the  lancet  be  not  at  hand,  either  of  the  others  can  be  used 
as  satisfactory  substitutes.  If  the  region  of  the  elbow  be  selected,  the 
median  cephalic  vein  is  preferred  on  account  of  its  greater  distance 
from  the  brachial  artery.  The  arm  should  be  constricted  by  a  band- 
age drawn  sufficiently  tight  to  obstruct  venous  return,  without  inter- 
fering with  arterial  circulation  :  this  will  cause  the  veins  to  become 
prominently  distended,  unless  the  patient  be  very  fleshy.  ■  The  veins 
should  be  well  defined  by  the  finger,  and  held  in  position  by  the 
thumb  or  finger  placed  just  below  the  point  for  incision,  which  is 
made  obliquely  to  the  transverse  diameter,  and  of  sufficient  depth  to 
freely  open  the  vessel  without  severing  it  (Fig.  181).  The  flow  may 
be  increased  by  causing  the  patient  to  firmly  grasp  a  stick  or  broom- 
handle  ;  it  may  be  impeded  by  the  interposition  of  the  subcutaneous 
fat,  which  should  be  pushed  aside.  The  amount  drawn  will  be  gov- 
erned by  the  strength  of  the  patient,  as  well  as  his  position.  If  stand- 
ing  or  sitting,  its  effects  will  be  felt  sooner  than  if  in  a  recumbent 
posture.  Usually,  however,  from  half  a  pint  to  a  pint  will  suffice. 
The  flow  is  arrested  by  removing  the  bandage  above  and  applying  the 
'finger  to  the  bleeding  point,  after  which  a  small  compress  is  placed 
over  the  incision,  and  confined  in  position  by  adhesive  plaster,  so  ar- 
ranged as  not  to  impede  the  venous  return. 

,  These  directions  will  apply  with  equal  force  to  venesection  in  all 
situations  other  than  the  external  jugular.  If  this  vein  be  selected, 
the  compress  is  placed  just  above  the  clavicle,  and  confined  in  position 
by  a  bandage  carried  under  the  opposite  axilla.  The  finger  is  then 
placed  above  the  point  of  proposed  incision,  and  the  vessel  opened  at 
a  right  angle  with  the  fibers  of  the  platysma  myoides  muscle.  The 
finger  must  always  be  placed  on  the  opening  before  the  compress  is 
removed,  in  order  to  prevent  the  entrance  of  air  into  the  circulation. 

Transfusion. — This  is  a  means  sometimes  employed  to  overcome 
the  exhaustion  produced  by  disease  or  the  loss  of  blood,  the  latter 
being  the  only  condition  to  which  it  can,  thus  far,  be  said  to  be  prac- 
tically adapted.  It  consists  in  conveying  the  blood  from  one  person 
to  another,  either  directly,  or  by  collecting  it  in  a  suitable  receptacle, 
removing  the  fibrin,  and  introducing  the  remaining  plasma  and  cor- 
puscles. The  dangers  to  be  avoided  are,  the  introduction  of  air,  blood- 
clots,  and  too  great  a  quantity  of  blood  into  the  patient's  veins,  which 
might  overpower  an  already  weakened  heart.  From  six  to  eight 
ounces  are  usually  sufficient,  and  should  be  thrown  in  slowly  and 
carefully,  watching  the  effects  upon  the  circulation,  respiration,  and 
sensorium  of  the  patient.  If  its  introduction  cause  a  depression  of 
the  pulse,  or  give  rise  to  nervous  tremors,  or  difficulty  in  breathing, 
it  should  cease  at  once.     The  blood  to  be  transfused  should  be  taken 


OPERATIONS   ON   VEINS,   CAPILLARIES,   ETC.  127 

from  a  person  of  strong  physique,  and  free  from  any  constitutional 
taint. 

Direct  Transfusion  from  Arm  to  Arm. — The  requirements  for 
this  are  an  apparatus  for  the  transmission  of  the  blood,  together  with  a 
pair  of  forceps  and  a  scalpel  to  open 
the  vessels,  and  a  basin  of  water  or  sa- 
line solution,  at  a  temperature  of 
about  100°  F.,  into  which  the  appa- 
ratus should  be  laid  to  impart  to  it 
the  requisite  degree  of  warmth,  and 
to  exclude  the  air.  The  arm  of  the 
donor  and  receiver  are  constricted 
above  the  point    for    incision,  as  in 


Fig.  182. — Introducing  the  tube  in  transfusion. 


phlebotomy  ;  the  skin  covering  the  distended  vessels  is  pinched  up, 
transfixed,  and  cut  through,  leaving  the  veins  exposed  at  the  bottom  of 
the  wounds  ;  they  are  then  seized  with  a  pair  of  forceps,  and  a  V-shaped 
opening  made  with  the  scissors  for  the  purpose  of  introducing  the  tube 
(Fig.  182).  The  tube  A  (Fig.  183)  is  then  taken  from  the  bottom  of 
the  basin,  and,  with  the  thumb  applied  to  its  larger  extremity  to  keep 
it  filled,  it  is  inserted  into  the  opening  in  the  vein  of  the  receiver  ;  the 
tube  B  is  inserted  in  like  manner  into  the  vein  of  the  donor,  after  which 
the  propelling  power — the  apparatus — likewise  filled  with  fluid  and 
kept  so  by  turning  the  stop-cocks,  is  attached  to  the  two  tubes  ;  the 
cocks  are  now  opened,  and  the  fluid  contained  in  the  instrument  is 
thrown  into  the  circulation  by  squeezing  the  bulb  C,  while  the  tube 
])*  ia  compressed.  After  the  bulb  C  is  emptied,  and  before  it  is  per- 
mitted to  expand,  the  compression  should  be  changed  from  I)"  to  D. 
If  the  bulb  be  now  allowed  to  expand,  it  will  become  filled  with  the 


128 


OPERATIVE   SURGERY. 


blood  of  the  donor,  which  can  be  injected  into  the  circulation  as  in 
the  preceding  instance.     The  bulb  should  be  allowed  to  fill  slowly, 


Fig.  183. — Direct  transfusion. 

and  the  amount  introduced  is  estimated  by  counting  the  number  of 
times  it  is  emptied.  After  the  operation  is  completed,  the  incisions 
are  treated  the  same  as  in  phlebotomy.  The  instrument  devised  by 
Fryer  (Fig.  184)  differs  from  the  former  in  being  cast  whole,  with  an 


Fig.  184. — Fryer's  transfusion  apparatus. 

additional  bulb,  which  does  away  with  the  metallic  couplings,  and 
presents  a  continuously  smooth  surface  to  the  blood  current ;  and, 
moreover,  the  additional  bulb  saves  time  by  producing  an  almost  con- 
tinuous current.  It  will  be  seen  that  a  funnel  is  added  to  this  instru- 
ment which  allows  it  to  be  employed  in  mediate  transfusion. 

Mediate  transfusion  is  collecting  the  blood  from  the  arm  of  the 
donor  and  injecting  it  into  the  circulation,  either  with  or  without  the 
removal  of  the  fibrin.  For  this  purpose  the  instrument  devised  by 
Collins  (Fig.  185)  can  be  especially  recommended.  It  consists  of  a 
pump  attached  to  a  funnel  in  such  a  manner  as  to  carry  the  blood 
easily  and  without  danger  of  coagulation  or  the  introduction  of  air. 


OPERATIONS   OX   VEINS,   CAPILLARIES,   ETC. 


129 


It  can  be  used  equally  well  with  the  detibrinated  or  with  the  un- 
whipped  blood  ;  with  the 
latter  it  is  particularly  con- 
venient, since  the  blood  can 
be  caught  in  the  funnel  and 
injected  while  flowing  from 
the  donor,  which  saves  time, 
and  avoids  the  blood-changes 
induced    by  exposure.      In 


^ 


^ 


^ 


Fig.  185. — Collins'  instrument 

the  use  of  this,  and  all  other  implements  brought  in  contact  with  the 
blood,  the  temperature  of  the  instrument,  and  of  the  blood  injected, 
should  be  kept  at  about  100° 
F.  by  means  of  warm  water, 
or  a  warm  saline  solution.* 

If  defibr  incited  Mood  be 
employed,  it  should  be  pre- 
pared by  agitation  (Fig.  186), 
after  being  collected  in  a 
vessel  of  the  temperature 
stated,  then  strained  -into 
the  funnel  of  the  instru- 
ment and  pumped  into  the 
system. 

The  introduction  into  the 
funnel,  or  into  the  bulbs,  of 
two  or  three  ounces  of  a  sa- 
line solution,  or  of  a  carbon- 
ate of  ammonia  solution, 
four    to    six   grains    to    the  Fig.  186.— Removing  fibrin. 

*  vP  Chloride  of  sodium 3  j- 

Chloride  of  potassium gr.  vj. 

Phosphate  of  soda £r.  iij. 

Carbonate  rf  soda Z  ,j. 

.Aquae §  xx. 

IL— Heat  to  100    I 

9 


130 


OPERATIVE   SURGERY. 


ounce,  prevents  the  entrance  of  air  into  the  instrument,  and  also  has 
a  stimulating  effect  upon  the  patient. 


Fig.  187. — Bull's  apparatus  for  injection  of  saline  solutions. 


Injection  of  Saline  Solutions. — The  introduction  into  the  veins, 
and  the  arteries,  of  various  solutions,  the  chief  ingredients  of  which 
are  common  salt  and  carbonate  of  soda,  is  highly  recommended.  The 
following  is  the  formula  of  Schwartz  :  Distilled  water,  32  ounces  ; 
common  salt,  1£  drachm  ;  officinal  solution  of  soda,  2  drops,  raised  to 
100  or  104°  F. 

Szumann  recommended  the  following  :  Water,  32  ounces  ;  com- 
mon salt,  1-j  drachm  ;  carbonate  of  soda,  15  grains.  The  saline  solu- 
tion on  page  129  is  suitable  for  this  purpose.  The  amount  of  fluid 
to  be  injected  will  depend  on  the  condition  of  the  patient,  also  upon 
its  effect.  It  is  seldom  that  less  than  eight  ounces  are  used,  frequently 
eighteen  or  twenty,  and  even  more  may  be  advisable.  The  introduc- 
tion of  the  fluid  should  be  made  slowly,  occupying  fifteen  or  twenty 
minutes,  by  means  of  the  apparatus  already  figured,  or  by  an  extem- 
porized siphon.  If  an  aspirating  needle  a  sixteenth  of  an  inch  in  diam- 
eter be  attached  to  a  small  rubber  tube,  connected  with  a  receptacle 
containing  the  solution,  and  raised  three  or  four  feet  above  the  pa- 
tient, no  trouble  will  be  experienced  in  carrying  the  fluid  into  the 
general  circulation.  The  vein  is  exposed,  distended,  and  punctured 
under  complete  antiseptic  precautions,  if  possible.  The  apparatus 
devised  by  Dr.  W.  T.  Bull,  of  this  city,  for  this  purpose,  is  admirable, 
owing  to  its  simplicity,  and  being  accompanied  by  the  saline  ingredi- 
ents necessary  to  charge  the  instrument  (Fig.  187).  These  fluids  seem 
to  meet  the  indications  quite  as  well  as  blood,  are  easily  obtained,  and 


OPERATIONS   ON    VEINS,    CAPILLARIES,   ETC. 


131 


do  not  expose  the  patient  to  the  dangers  attendant  on  the  use  of  the 
latter. 

Intro-venous  injection  of  milk  has  been  done  to  counteract  the 
conditions  similar  to  those  calling  for  the  use  of  blood.  The  milk 
should  be  freshly  drawn  from 
the  cow  and  covered  with  a 
fine  gauze,  through  which  it  is 
strained  into  a  transfusion  in- 
strument, which  can  be  ex- 
temporized by  joining  a  glass 
funnel  to  one  end  of  a  rub- 
ber tube,  and  to  the  other  a 
small  conducting  canula. 

If  the  canula  be  introduced 
into  the  vein,  and  the  funnel 
be  raised  after  having  been 
filled  with  six  or  eight  ounces 
of  milk,  the  force  of  gravity 
will  become  the  propelling 
agent. 

Arterial  transfusion  has 
been  advocated  on  the  basis 
that  it  conveys  the  blood  more 
equably  to  the  heart,  with  less 
danger  of  exciting  undue  dis- 
turbance of   the  circulation. 

The  admission  of  a  small  amount  of  air  does  no  harm,  and  the  dan- 
ger of  phlebitis  is  avoided.  The  vessel  selected  should  be  the  radial 
at  the  wrist,  or  the  posterior  tibial  at  the  ankle,  either  one  of  which 
is  exposed,  and  three  ligatures  are  placed  around  it ;  the  distal  one  is 
ligatured  and  the  proximal  one  tightened  sufficiently  to  interrupt  the 
circulation  in  the  vessel.  The  vessel  is  now  opened  and  the  tube  in- 
serted and  tied  in  position  by  the  third  or  middle  ligature,  then  the 
proximal  one  is  loosened  and  the  fluid  injected  into  the  circulation. 
It  i3  better  to  inject  the  fluid  against  than  with  the  natural  flow  of  the 
blood  current,  to  avoid  over-distention  of  the  capillaries.  As  soon  as 
the  injection  of  the  fluid  is  completed  the  proximal  one  is  tied,  and 
the  intervening  portion  of  the  vessel  removed  with  the  tube.  The 
vein  may  be  tied  in  venous  transfusion  with  two  ligatures  in  the  fol- 
lowing manner  :  Tie  the  distal  one,  open  the  vein,  introduce  the  tube, 
then  tie  the  proximal  one,  including  the  tube;  this  will  prevent  all 
ot  hlood. 

Operations  on  the  Capillaries.  —  This  system  of  vessels,  like  the 
venous,  may  undergo  dilatation  of  sufficient  size  to  create  distinct  but 
slowly  developing  and  painless  deformities,  or  tumors.     The  morbid 


Fig.  188.— Straining  the  blood. 


J32  OPERATIVE   SURGERY. 

process  may  be,  and  usually  is,  limited  entirely  to  the  capillaries  of 
the  integument ;  however,  the  larger  vessels  are  not  infrequently  in- 
volved, in  the  beginning,  or  during  their  development  ;  they  likewise 
vary  in  size,  shape,  and  color.  The  simplest  form  is  known  as  the 
"■  Mother's  mark,"  "  Birth-mark,"  etc. 

A  birth-mark  can  be  treated  by  pressure,  caustic,  hot  needles,  vac- 
cination, etc.,  depending  upon  its  size  and  situation.  It  is  not  well 
to  interfere  with  it  at  all  except  by  simple  means,  unless  it  increases 
rapidly  in  size.  The  majority  of  these  growths  will  disappear  of  them- 
selves before  their  presence  becomes  a  source  of  annoyance  or  regret  to 
the  possessor.  There  are,  however,  several  simple  means  which  will 
often  hasten  their  departure — the  use  of  simple  compresses,  repeated 
application  of  collodion,  or  vaccination,  if  the  birth-mark  be  located 
suitably  therefor.  The  following  method,  introduced  by  Dr.  Squire 
some  time  since,  which  bade  fair  at  one  time  to  meet  the  desired  end, 
can  be  employed  : 

The  "  mark  "  is  frozen  with  an  ether  spray,  and  numerous  parallel 
incisions  are  made  about  one  sixteenth  of  an  inch  apart  and  extending 
the  same  depth,  and  the  whole  covered  with  blotting-paper,  held  upon 
it  with  sufficient  force  to  prevent  any  gaping  of  the  cuts  and  escape 
of  blood  ;  after  fifteen  or  twenty  minutes  the  paper  is  thoroughly  wet 
with  water  and  removed.  Sometimes  a  thin  underlying  clot  of  blood 
will  be  found  ;  this  must  be  carefully  washed  away  with  water  and  a 
soft  brush.  It  is  sometimes  necessary  to  repeat  the  operation,  when 
the  incisions  should  be  made  at  right  angles  to  the  previous  incisions. 
If  proper  care  be  taken,  in  suitable  cases  a  perfect  cure  is  secured 
without  any  scarring.  The  injection  of  ergot,  liquor  ferri  subsulphat- 
is,  or  various  other  astringents,  has  been  recommended.  They  are, 
however,  uncertain  in  their  action,  and  are  liable  to  be  followed  by- 
inflammation,  ulceration,  and  sometimes  by  embolism.  The  solutions 
can  be  injected  by  aid  of  the  ordinary  hypodermic  syringe,  three  or 
four  drops  at  a  time,  in  various  portions  of  the  growth,  or,  red-hot 
needles  can  be  introduced  at  different  points.  The  application  of 
red  heat  around  the  base  and  over  the  surface  of  the  growth  by  means 
of  the  Paquelin  cautery  is  an  admirable  method,  provided  it  involves 
the  skin  alone  or  only  the  capillaries  in  the  tissue  immediately  be- 
neath it.  It  is  usually  followed  by  more  or  less  disfigurement,  depend- 
ing upon  the  extent  of  the  cauterization. 

Subcutaneous-  Ligaturing. — If  the  naevus  be  of  large  size,  persist- 
ent, of  a  dark  color,  and  markedly  elevated,  it  is  suitable  for  this  meas- 
ure, which  is  done  in  several  ways,  depending  upon  the  size  and  shape 
of  the  tumor,  and  fancy  of  the  operator. 

Fig.  189  represents  a  simple  method.  In  it  the  needle,  armed 
with  a  strong,  well-carbolized  hemp  or  silk  ligature,  is  thrust  through 
the  integument  at  its  base,  carried  as  far  as  possible  around  the  base, 


OPERATIONS   ON   VEINS,   CAPILLARIES,   ETC. 


133 


and  passed  out,  to  be  again  introduced  at  the  point  of  exit,  and  car- 
ried still  farther  around,  and  pushed  through  as  before,  and  so  on 
until  it  is  caused  to  emerge  at  the  first  point  of  insertion  ;  the  ends 
are  then  tied  in  a  firm,  hard  knot. 

In  Fig.  190  a  double  ligature   is  carried  through  the   base   and 


Fig.  189.— By  a  sin- 
gle ligature. 


Fig.  190 —By  a  double 
ligature. 


Fig.  191.— Ligation  in  quar- 
ter sections. 


divided  ;  each  portion  is  then  carried  around  its  half  of  the  base  as  be- 
fore, and  tied.  This  is  applicable  to  those  having  a  larger  base.  Fig. 
191  represents  the  application  of  the  ligature  to  cpiarter-sections  of 
the  base.  It  is  employed  when  the  growth  is  large.  Pass  a  double 
ligature  through  the  center  of  the  base,  cut  the  loop  near  to  its  center, 
leaving  one  end  of  the  divided  thread  in  the  eye  of  the  needle  ;  then, 
after  threading  the  needle  with  the  other  end  of  the  portion  of  the 
ligature  which  was  liberated  by  the  division  of  the  loop  (Fig.  192), 
pass  the  needle  through  the  base  at  right  angles  to  its  primary  course. 
The  ends  are  then  to  be  firmly  tied  after  the  integument  has  been  in- 
cised, to  allow  the  ligature  to  sink  deeply  into  the  base,  as  well  as  to 
avoid  the  pain  and  ulceration  incident  to  the  constriction  of  the  in- 


Fig.  192. — Quarter  sec- 
tions, second  step. 


Fig.  193.— Tyinj 
ature. 


Fig.  194. — Ligature  of  elon- 
gated base. 


tegument  (Fig.  193).  It  will  simplify  the  selection  and  uniting  of  the 
proper  extremities  if  one  half  the  ligature  be  colored  before  its  primary 
introduction.  Fig.  194  represents  the  ligation  of  a  growth  with  an 
elongated  base.  In  this  the  double  ligature  is  required,  and  should  be 
colored  as  suggested  above  ;  pass  it  through  the  base  from  side  to  side, 
commencing  and  terminating  just  outside  of  the  extreme  limits  of  the 
growth  ;  if  the  white  loops  be  now  divided  on  one  side  and  (lie  black 
on  the  other,  independent  sets  of  ligatures  will  be  had,  which  should 
be  tied  ;  the  skin  coming  within  the  grasp  of  each  ligature  is  incised 


134  OPERATIVE   SURGERY. 

as  in  the  preceding  instance.  The  separation  of  the  growth  is  has- 
tened by  the  use  of  an  elastic  or  rubber  ligature,  applied  in  a  similar 
manner. 

Division  and  Ligation. — Cirsoid  growths  of  the  scalp  can  be  suc- 
cessfully treated  by  making  a  free  incision  nearly  around  and  outside 
of  them,  down  to  the  periosteum,  leaving  that  portion  of  the  growth 
that  contains  the  largest  vessel  undisturbed  to  form  a  pedicle  to  nour- 
ish the  flap.  The  flap  is  raised  and  all  bleeding  points  are  tied,  after 
which  it  is  kept  separated  from  its  former  bed  by  antiseptic  gauze 
until  the  new  surfaces  granulate.  The  granulating  surfaces  are  then 
placed  in  contact,  and  soon  unite,  thereby  destroying  the  growth 
without  loss  of  substance.  If  the  pulsations  in  the  flap  continue  for 
four  or  five  days,  the  dilated  vessel  entering  it  should  be  tied  at  a 
distance  from  the  pedicle.  The  hemorrhage  is,  to  a  degree,  con- 
trolled during  the  primary  operation  by  passing  a  strong  rubber 
band  around  the  head,  beneath  which  compresses  are  placed  corre- 
sponding in  situation  to  the  course  of  the  vessels  that  supply  the 
scalp.  The  bleeding  points  can  also  be  closed  by  direct  pressure 
against  the  underlying  bone  ;  yet,  notwithstanding  these  means,  the 
loss  of  blood  may  be  quite  severe,  and  the  operation  should  not  be 
attempted  if  the  patient  be  already  exsanguinated  or  otherwise  debili- 
tated. Care  should  be  taken  to  form  a  pedicle  of  sufficient  width  to 
nourish  the  flap  ;  from  half  an  inch  to  an  inch,  depending  on  the  size 
of  the  flap,  has,  in  my  experience,  been  ample  for  the  purpose.  If 
the  dressing  be  applied  too  firmly,  the  integrity  of  the  flap  will  be  en- 
dangered. 


CHAPTER  VI. 

OPERATIONS  ON  THE  NERVOUS  SYSTEM. 

The  brain,  spinal  cord,  and  the  nerves  arising  from  the  cerebro- 
spinal axis,  owing  to  the  various  morbid  processes  and  injuries  to 
which  they,  together  with  their  coverings,  are  subjected,  are  often  the 
seat  of  common  and  yet  important  surgical  procedures. 

Hydrocephalus.— -Tapping  for  the  removal  of  the  superfluous  fluid 
is  the  only  practical  surgical  procedure  to  which  this  condition  is 
amenable.  This  may  be  done  with  a  small  aspirating  trocar,  or,  what 
is  better,  with  an  aspirator.  In  either  instance  the  puncturing  agent 
is  introduced  through  the  anterior  fontanelle,  close  to  its  outer  border, 
and  passed  perpendicularly  into  the  fluid  accumulation,  cautiously 
avoiding  the  brain  substance  when  possible.    The  fluid  must  be  slowly 


OPERATIONS   OX   THE    NERVOUS   SYSTEM.  135 

withdrawn,  accompanied  by  moderate  and  equable  pressure  upon  the 
external  surface  by  means  of  a  skull-cap  bandage.  Whenever  any 
manifestations  referable  to  the  circulatory  or  nervous  centers  appear, 
the  needle  should  be  withdrawn  and  the  puncture  carefully  closed 
with  a  catgut  suture  and  dressed  antiseptically.  Often  the  removal  of 
less  than  three  or  four  ounces  will  cause  feebleness  of  the  pulse,  con- 
traction of  the  pupil,  and  evidences  of  approaching  convulsion.  After 
the  withdrawal  of  the  fluid,  gentle  and  uniform  pressure  should  be 
maintained  by  aid  of  bandages,  adhesive  plaster,  or  a  tightly-fitting 
perforated  rubber  cap.  Care  is  necessary,  else  the  combined  pressure 
of  the  reaccumulating  fluid  and  external  dressing  will  cause  alarming 
symptoms. 

Meningocele  is  a  protrusion  of  the  meninges  of  the  brain,  caused 
often  by  an  accumulation  of  the  hydrocephalic  fluid  within  the  cra- 
nium, and  must  of  necessity  occur  before  the  closure  of  the  fontanelles. 
It  mav  be  present  at  any  point  of  separation  between  the  cranial 
bones,  although  it  occurs  more  frequently  at  the  posterior  fontanelle 
than  elsewhere.  As  a  rule,  little  can  be  done,  other  than  to  pro- 
tect the  tumor  from  external  irritation.  If  it  have  a  well-defined 
pedicle,  this  can  be  clamped  and  the  fluid  withdrawn,  either  by  in- 
cision or  with  a  small  trocar.  The  clamp  must  be  applied  with  cau- 
tion, else  the  pressure  caused  by  it  may  produce  convulsions  or  other 
nervous  phenomena.  If  it  be  determined  to  puncture  it,  a  small 
amount  of  fluid  may  be  withdrawn,  when  the  clamp  can  be  the  more 
readily  adjusted.  As  long  as  the  pedicle  is  open,  any  operative  in- 
terference is  liable  to  be  followed  by  death  from  a  resulting  menin- 
gitis. If  the  pedicle  be  occluded,  the  sac  may  be  incised  and  the 
tumor  removed.  In  all  instances  where  it  is  removed,  sufficient  in- 
tegument should  be  left  to  insure  a  complete  and  proper  closure  of  the 
divided  surfaces. 

Hydro-rachm. — This  is  a  congenital  defect,  comprising  a  cleft  in 
the  laminae  of  the  vertebra?,  and  a  protrusion  of  the  membranes  of  the 
spinal  cord.  It  occurs  most  frequently  in  the  lumbar  region,  al- 
though it  is  found  in  the  other  portions  of  the  spinal  column.  Vari- 
ous operative  expedients  have  been  employed  to  cure  the  defect, 
nearly  all  of  which  have,  at  one  time  or  another,  resulted  in  occasional 
cures. 

The  two  methods  which  have  secured  the  best  results  are  :  1.  Re- 
peated punctures  with  a  small  needle  at  various  points  through  the 

-  of  the  Back,  followed  by  gentle  and  uniform  pressure  over  the 
surface.  2.  Consists  of  injecting  into  the  sack,  after  having  been  par- 
tially emptied  of  its  fluid,  one  or  two  drachms  of  the  iodo-glycerin 
solution,  which  is  made  by  dissolving  ten  grains  of  iodine  and  thirty 
grains  of  iodide  of  potassium  in  one  ounce  of  glycerin.  Exercise  cau- 
tion that  none  of  the  fluid  escapes  after  the  operation.     This  must  be 


136 


OPERATIVE  SURGERY. 


repeated  from  time  to  time,  always  allowing  the  irritation  due  to  the 
previous  operation  to  subside  before  it  is  again  repeated. 

Results.— -The  latter  method  has  been  very  successful.  Of  forty- 
four  cases  treated,  thirty-five  were  cured. 

Trephining  the  Cranium  is  an  operation  which  is,  without  doubt, 
performed  more  frequently  than  the  requirements  of  many  of  the  cases 


?ig.   195. — 

Fig.  196.— 

Fig.    197.— Gait's 

Fig.  198.— 

Fig.  199.— 

Fig.  200. 

Crown  tre- 

Handle of 

trephine. 

Elevator. 

Elevator. 

— Eleva- 

phine. 

trephine. 

tor. 

warrant.     In   every  instance,  before  attempting  it,  the  indications 
should  be  most  carefully  studied. 

The  special  instruments  required  for  the  operation  are  the  trephine 
(Figs.  195, 196, 197),  the  conical,  or  Gait's,  being  by  far  the  safer  ;  an 
elevator  (Figs.  198,  199,  200)  and  rongeur  (Fig.  201),  sequestrum  for- 
ceps (Figs.  202  and 
203),  gouges  and  mal- 
lets (Figs.  204,  205, 
206,  207,  208).  The 
traditional  tooth- 
pick, and  the  brush, 
to  remove  the  dust 
from  the  track  of  the 
trephine,  while  not 
absolutely  necessary,  have,  nevertheless  (especially  the  former),  be- 
come so  closely  associated  with  the  operation  as  to  be  entitled  to  a  most 
respectful  consideration.     The  patient  is  prepared  by  shaving  the  head 


Fig.  201.— Rongeur. 


OPERATIONS   OX   THE   NERVOUS   SYSTEM.  137 

for  a  considerable  distance  around  the  seat  of  the  proposed  operation. 


Fig.  202. — Van  Buren's  sequestrum  forceps. 

If  unconscious,  an  anaesthetic  is  unnecessary.     Strict  antiseptic  pre- 
cautions should  be  enjoined. 

Operation. — Make  an  incision  of  an  oval  shape  through  the  scalp 


Fig.  203. — Ferguson's  sequestrum  forcep9. 

down  to  the  bone,  expose  the  portion  of  the  cranium  be  pot  oerated 
upon,  and  at  the  same  time  avoid  large  vessels  and  secure  good  drainage 
when  possible.    Lay  back  the  integumentary  flap,  together  with  the 


Fig.  201.—     IV;.     205.     IV;.  206.— Szy-       FlO.  207.— Hoffman's         FlO.  208.— Lead 
Straight  — Curved       m&nowiky's  gouge  forcepi,  mullet, 

gouge.  gouge.  gouge. 


138 


OPERATIVE   SURGERY. 


Fig.  209. — Course  of  arteries  and  sinuses. 


periosteum  covering  the  portion  of  bone  to  be  removed.    Lower  the  cen- 
b  ter-pin  a  little  below  the  teeth 

of  the  trephine,  and  fasten  it 
firmly  in  position  by  means  of 
its  adjusting  screw ;  place  the 
point  of  the  center-pin  as 
nearly  as  practicable  upon 
that  portion  of  the  solid  and 
undepressed  bone  which, 
when  removed,  will  allow  the 
best  opportunity  of  elevating 
that  which  is  depressed,  pro- 
vided, however,  that  it  be  not 
placed,  when  avoidable,  over 
the  course  of  the  middle  me- 
ningeal artery,  or  a  large  sinus 
(Fig.  209).  The  trunk  of  the 
middle  meningeal  artery  (Fig.  209,  a)  is  located  an  inch  and  a  half  be- 
hind theexternal  angu- 
lar process  of  the  fron- 
tal bone,  and  the  same 
distance  above  the  zy- 
goma. The  median  line 
of  the  skull,  from  the 
root  of  the  nose  to  the 
occipital  protuberance, 
corresponds  to  the  su- 
perior longitudinal  si- 
nus (Fig.  209,  b).  The 
course  of  the  lateral  si- 
nus (Fig.  209,  c)  is  indi- 
cated by  a  line  drawn 
from  the  occipital  pro- 
tuberance to  the  ante- 
rior border  of  the  mas- 
toid process.  Bear  firm- 
ly upon  the  instru- 
ment, at  the  same  time 
turn  it  quickly  from 
right  to  left,  till  asuita- 
ble  track  is  established 
to  retain  it  in  position 

(Fig.  210) .  The  center-  FIG.  210.— Applying  the  cylindrical  trephine, 

pin  is  then  withdrawn 
and  fastened  back  in  place,  otherwise  it  may  perforate  the  membranes. 


OPERATIONS   OX   THE   NERVOUS  SYSTEM.  130 

The  instrument  must  be  held  perpendicularly  to  the  point  of  sec- 
tion, and  the  pressure  evenly  distributed  ;  if  not,  one  side  of  the  circle 
will  be  penetrated  more  quickly  than  the  other,  thereby  jeopardizing 
the  integrity  of  the  membranes.  During  the  process  the  trephine 
must  be"  frequently  raised  from  the  track,  that  it  maybe  cleared  of 
bone-dust,  the  color  of  which  should  be  carefully  noticed  ;  at  first  it 
is  of  a  pale  white,  but  as  soon  as  the  diploe  is  reached  it  becomes  red- 
dened ;  from  this  time  on  the  tooth-pick  must  be  frequently  used  to 
clear  out  the  track  as  well  as  to  detect  the  first  point  of  complete  sec- 
tion. But  little  pressure  is  now  allowable,  since  to  use  it  might  force 
the  crown  of  the  instrument  through  the  membranes  and  into  the 
brain  structure  itself,  especially  if  the  trephine  be  of  a  horizontal  pat- 
tern. Gait's,  or  the  conical  trephine  (Fig.  197),  is  far  safer  than  the 
crown  pattern,  since,  as  soon  as  the  inner  table  is  divided,  it  is  con- 
verted into  a  screw  and  becomes  immovably  fixed  in  the  opening.  If 
the  button  of  bone  be  percussed  with  the  handle  of  a  scalpel  or  forceps, 
it  will  emit  a  low-pitched  sound,  and  vibrate  when  a  considerable  por- 
tion of  the  circle  is  cut  through  ;  moreover,  it  can,  probably,  be  raised 
from  its  bed  at  this  time  by  the  aid  of  the  elevator.  As  soon  as  the 
button  is  removed,  the  elevator  is  inserted  beneath  the  depressed  por- 
tion, and  it  is  raised  to  its  proper  level. 

This  is  sometimes  difficult  to  accomplish,  owing  to  the  dovetailing 
of  the  fragments.  The  solid  bone  is  used  as  a  fulcrum  when  much  force 
is  necessary.  If  great  force  be  employed,  and  a  fragment  be  suddenly 
loosened,  its  distal,  sharp,  or  jagged  border  may  cut  through  the  mem- 
branes ;  it  is  therefore  necessary  that  force  be  used  in  a  guarded  manner. 

All  detached  fragments  are  removed  ;  those  that  will  retain  their 
position  when  elevated,  owing  to  continuity  of  structure,  may  be  al- 
lowed to  remain.  All  projecting  points  of  bone  must  be  cut  away 
with  the  rongeur,  else  the  pulsation  of  the  brain  may  cause  them  to 
perforate  the  dura  mater.  Clots  of  blood  and  pus  are  likewise  to 
be  cleared  out  by  a  stream  of  antiseptic  fluid.  If  the  compressing 
agents  be  below  the  dura  mater,  it  may  be  opened  sufficiently  to  ad- 
mit of  their  escape  ;  before  this  is  done,  however,  their  presence 
should  be  clearly  established.  If  the  dura  mater  be  lacerated,  it 
may  be  closed  by  fine  catgut  sutures,  especially  Avhen  the  opening  is 
large  enough  to  predispose  the  formation  of  hernia  cerebri.  If  the 
middle  meningeal  branches  be  divided  or  a  sinus  opened,  the  hemor- 
rhage is  controlled  by  antiseptic  compresses,  so  applied  ae  not  to  exert 
undue  procure  on  the  brain.  If  the  membranes  be  lacerated,  the 
fragments  of  bone  removed  must  be  fitted  to  each  other,  in  order 
that  the  absence  of  any  osseous  portion  may  be  ascertained  and  it  be 
sought  after.  The  opening  in  the  skull  made  by  the  trephine  can  he 
enlarged  more  rapidly  and  safely  by  the  rongeur  (Fig.  201)  than  by 
repeated  applications  of  the  trephine. 


140 


OPERATIVE   SURGERY. 


The  wound  should  now  be  thoroughly  cleansed  with  carbolic  acid, 
the  flaps  adjusted,  suitable  drainage  established,  and  the  antiseptic 
dressing  applied.  It  is  often  possible  to  elevate  the  fragments  with- 
out the  use  of  the  trephine,  an  expedient  that  should  always  be  tried, 
if  a  reasonable  prospect  of  success  be  apparent. 

Results. — The  nature  of  the  cause  calling  for  the  operation,  the 
length  of  time  intervening  prior  to  its  performance,  and  the  ability  to 
secure  complete  drainage  and  asepsis,  are  the  chief  factors  that  modify 
the  prognosis.  A  death-rate  of  from  four  to  fifteen  per  cent,  is  a  fair 
estimate  in  civil  practice. 

The  advance  which  is  being  made  in  cerebral  localization  is  worthy 
of  the  closest  scrutiny  of  the  operating  surgeon.  Not  only  should  he 
operate  on  the  skull  in  the  accepted  sense  of  the  term,  but  he  should 
also  note  the  exact  seat  of  the  lesion  calling  for  his  action.  The  va- 
riations in  the  symptoms,  before  and  after  the  procedure,  should  like- 
wise be  carefully  scrutinized.  The  precise  seat  of  an  operation  can  be 
determined  by  measurements  made  from  established  points,  as  from 
the  external  auditory  meatus,  the  external  angular  process  of  the 


Pig.  211.— Relation  of  chief  fissures  and  convolutions  to  external  surface  of  skull,  a 
Inferior  frontal  fissure,  b.  Superior  frontal  fissure,  c.  Fissure  of  Rolando,  d.  Calloso- 
marginal  fissure,  e.  Inter-parietal  fissure.  /.  Paricto-occipital  fissure,  q.  Parallel  fis- 
sure,    h.  Pissure  of  Sylvius. 

frontal  bone,  various  sutures,  etc.  Fig.  211  shows  the  relations  borne 
by  important  convolutions  and  fissures  of  the  cerebrum  to  the  su- 
tures, and  to  other  external  points  on  the  skull.  Fig.  212,  showing 
the  exterior  of  the   skull,   is  of  especial  importance  when   studied 


OPERATIONS  OX   THE   NERVOUS   SYSTEM. 


141 


Fig.  212. — Location  of  fissure  of  Rolando  (R)  and  the  special  areas. 

in  connection  with  the  preceding  figure  ;  upon  it  are  indicated  the 
measurements  necessary  to  properly  locate  the  underlying  convo- 
lutions with  which  definite  functions  have  been  found  to  be  asso- 
ciated. 

Operations  on  the  Nerves  of  the  Cranium.— It  may  become  neces- 
sary, owing  to  neuralgia,  spasm,  tremor,  etc.,  after  all  ordinary  means 
have  failed,  to  operate  upon  the  trunk  of  the  nerve  involved,  either 
by  division,  excision,  or  stretching.  The  first  method  can  afford  but 
temporary  relief,  since  the  divided  extremities  will  speedily  unite. 

If  excision  be  done,  not  less  than  two  inches,  if  possible,  should  be 
removed  from  the  continuity  of  the  trunk  ;  otherwise,  at  a  greater  or 
lesser  period,  the  extremities  will  become  united.  If  the  nerve  be  a 
small  one,  the  tendency  to  union  is  less,  but  the  rule  to  remove  a  long 
piece  must  not  be  deviated  from.  Stretching  consists  in  cutting  down 
on  the  affected  nerve,  seizing  it  with  the  fingers,  and  making  firm  and 
steady  traction  for  from  half  a  minute  to  a  minute.  It  is  applied 
more  properly  to  the  large  nerves,  and  those  which  can  not  be  divided 
without  the  sacrifice  of  important  functions. 

Supra-Orbital  Nerve.— This  may  be  divided  or  excised  at  its  exit 
from  the  supra-orbital  foramen  or  notch  at  the  junction  of  the  inner 
and  middle  thirds  of  the  supra-orbital  arch.  It  is  covered  by  integu- 
ment,  fascia,  and  the  combined  libers  of  the  orbicularis  oculi,  occipito- 
frontalis,  and  oomigator  snperoilii  muscles. 

To  divide  it,  locate  the  notch  by  the  lingers  of  the  left  hand,  then 


142  OPERATIVE   SURGERY. 

pass  the  point  of  a  narrow  bistoury  beneath  the  integument,  from  its 
inner  to  its  outer  side  ;  turn  the  edge  backward,  and  cut  firmly  down 
and  across  the  opening  upon  its  inferior  wall. 

Excision  and  Stretching —The  nerve  can  be  found  by  elevating  the 
brow  and  making  an  incision  between  it  and  the  lid,  one  inch  in  length, 
through  the  tissues  down  upon  the  site  of  the  nerve  ;  the  connective 
tissue  is  then  displaced  by  a  director  and  its  branches  are  sought  for, 
and  excised  or  stretched,  as  seems  better.  The  nerve  may  be  pulled 
out  with  a  small  blunt  hook  from  the  roof  of  the  orbit,  and  excised 
before  it  enters  the  foramen  ;  or  it  may  be  stretched  and  allowed  to 
remain. 

The  Infra-  Orbital  Nerves  are  the  terminal  branches  of  the  supra- 
maxillary  division  of  the  fifth  pair  ;  they  escape  from  the  infra-orbital 
foramen, 

The  infra-orbital  foramen  is  about  four  lines  below  the  lower  edge 
of  the  orbit,  and  nearly  on  a  line  extending  from  the  bicuspid  teeth 
to  the  supra-orbital  foramen.  The  nerve  may  be  divided  through  the 
mouth  by  first  recognizing  the  location  of  the  foramen,  and  placing 
the  finger  upon  it ;  then  make  a  narrow  incision,  beginning  at  the 
fold  of  the  cheek  and  maxilla,  carrying  it  upward  in  the  line  before 
indicated,  till  within  a  short  distance  of  the  foramen,  when  with  a 
sharp-pointed  pair  of  scissors  the  nerves  are  divided  as  they  emerge. 
They  may  also  be  divided  through  an  external  kicision  made  directly 
down  upon  the  foramen. 

In  the  latter  the  incision  should  be  crescentic  with  the  concavity 
upward,  and  be  located  about  one-half  inch  below  the  lower  border  of 
the  orbit ;  the  muscles  and  cellulo-adipose  tissue  are  displaced,  nerves 
isolated  from  the  vessels  and  divided.  The  nerves  may  be  divided 
subcutaneously  at  this  situation  by  a  slender-bladed  knife  passed  in 
the  line  of  their  emergence,  and  its  edge  directed  toward  the  inferior 
wall  of  the  canal. 

The  Superior  Maxillary  Nerve. — This  may  be  excised,  divided,  or 
stretched  in  its  course  along  the  floor  of  the  orbit,  or  at  its  exit  from 
the  foramen  rotundum.  It  may  be  reached  on  the  floor  by  passing  a 
tenotome  about  an  inch  backward  in  the  line  of  its  course,  turning 
the  edge  downward,  and  cutting  upon  and  through  the  thin  floor  of 
the  orbit.  Its  termination  at  the  infra-orbital  foramen  can  then  be 
exposed,  and  the  severed  portion  pulled  out  (Langenbeck).  Through 
a  narrow  incision  of  the  soft  parts,  in  this  situation,  a  blunt  hook  can 
be  introduced,  the  nerve  caught  up  and  stretched.  The  whole  of  the 
nerve  can  be  removed  from  the  canal,  and  sometimes  farther  poste- 
riorily,  if  an  incision  be  made  about  an  inch  and  a  half  in  length  along 
the  lower  border  of  the  orbit,  the  tissues  elevated  and  the  nerve  iso- 
lated from  the  artery,  raised  on  a  hook  and  divided  ;  or  by  pulling 
out  the  central  portion,  either  by  a  ligature  previously  applied,  or 


OPERATIONS   OX   THE   NERVOUS   SYSTEM. 


143 


with  a  pair  of  forceps.  If  the  more  formidable  operation  of  its  division, 
as  it  escapes  from  the  foramen  rotundum,  be  attempted,  the  initiatory- 
incision  through  the  soft  parts  should  be  of  a  shape  and  extent  to 
best  expose  the  site  of  the  proposed  operation  ;  the  V,  +,  U,  T  shaped 
ones  are  selected,  according  to  the  wish  of  the  operator.  In  either 
instance  its  central  portion  should  correspond  as  nearly  as  possible  to 
the  infra-orbital  foramen.  After  the  flap  is  raised,  the  crown  of  a 
large  trephine  or  drill  is  applied  to  the  bone  so  as  to  open  into  the 
antrum  along  the  course  of  the  nerve,  which  is  carefully  followed 
backward  to  the  spheno-maxillary  fossa  by  cutting  away  the  floor  of 
the  canal  with  a  sharp,  delicate  chisel.  It  is  then  carefully  isolated 
from  the  tissues  in  the  fossa  back  to  the  foramen  of  exit,  and  divided 
with  a  pair  of  curved  scissors  (Carnochan).  The  internal  maxillary 
artery  runs  through  the  fossa,  and  should  be  carefully  avoided.  If  it 
be  cut,  it  should  be  ligatured  if  possible  ;  not  infrequently  firm  pressure 
will  check  the  hemorrhage  ;  when  other  means  fail,  ligaturing  of  the 
external  carotid  will  become  necessary. 

The  posterior  wall  of  the  antrum  is  cpiite  vascular,  and,  when 
broken,  or  cut  through  by  the  small  trephine,  it  often  bleeds  vigor- 
ously. There  seems  to  be  good 
ground  for  the  belief  that  quite 
as  good  results  follow  an  excision 
made  anterior  to  Meckel's  gangli- 
on as  behind  it.  In  either  in- 
stance the  operation  ought  not  to 
be  attempted  unless  a  strong  light 
can  be  thrown  upon  the  field  of 
action. 

The  second  and  third  branches 
of  the  fifth  pair  can  be  exposed 
at  their  exit  from  the  skull  by 
the  ingenious  method  of  Prof. 
Pancoa>t. 

Operation. — Make  an  incision 
the  entire  width  of  the  perpen- 
dicular ramus  of  the  lower  jaw 
near  where  it  joins  the  body; 
connect  to  its  extremities  two  par- 
allel incisions  carried  upward  to 
the  zygoma  and  malar  bone,  care- 
fully avoiding  Steno's  duct  (Fig. 
813).  Dissect  this  flap  down  to  the  bone,  its  upper  border  remaining 
attached  at  the  zygoma.  The  coronoid  process  is  now  sawn  off,  de- 
tached from  the  temporal  muscle  and  removed.  The  temporal  muscle 
is  then  pushed  beneath  the  zygoma.    The  fatty  matter  now  exposed  is 


213. — Pancoast's  lines  of  incision. 


144 


OPERATIVE   SURGERY. 


removed,  and  the  internal  maxillary  artery  within  it  is  ligatured.  The 
upper  head  of  the  external  pterygoid  is  detached  from  the  greater 
wing  of  the  sphenoid  bone  by  the  finger,  and  all  hemorrhage  checked, 
when  the  nerves  within  the  zygomatic  fossa  are  readily  seen,  and  can 
be  easily  excised. 

If  it  be  desired  to  expose  the  second  branch  as  it  crosses  the  spheno- 
maxillary fossa,  extend  the  incisions  upward  and  seek  the  spheno- 
maxillary fissure  at  the  anterior  lacerated  foramen.  The  nerve  should 
now  be  carefully  isolated  and  a  strong  ligature  passed  around  it.  This 
last  step  is  often  attended  with  difficulty,  especially  when  the  fissures 
leading  to  it  are  narrow.  If  more  room  be  necessary,  the  posterior 
wall  of  the  antrum  can  be  crushed  in. 

The  Inferior  Dental  Nerve. — This  nerve  may  be  divided,  excised, 
or  stretched,  before  it  enters  the  jaw,  in  its  course  through  it,  and  at 
its  exit  from  the  mental  foramen.  In  the  first  situation  an  incision 
is  made  about  an  inch  and  a  half  in  length  along  the  anterior  border 
of  the  vertical  ramus  of  the  jaw,  within  the  mouth  down  to  the  ante- 
rior fibers  of  the  internal  pterygoid  muscle  ;  the  connective  tissue  be- 
tween this  muscle  and  the  inner  surface  of  the  ramus  is  now  pushed 
aside,  and  the  nerve  detected  as  it  enters  the  canal.  The  small  spine 
surmounting  the  opening  for  the  entrance  of  the  vessel  and  nerve  can 
be  quite  readily  located,  and  will  be  a  valuable  guide  to  the  nerve  as 
it  enters  the  dental  canal.  It  can  now  be  isolated,  hooked  up,  and 
divided.  About  an  inch  and  a  half  can  be  easily  excised  in  this  situ- 
ation, if  after  its  isolation  a  strong  ligature  be  thrown  around  it  and 
tied.  It  is  then  divided  by  curved' scissors  as  it  enters  the  canal  ; 
traction  by  means  of  the  ligature  can  then  be  made,  which  will  not 
only  draw  the  nerve  down  to  admit  of  the  division  of  the  proximal  end, 
but  also  add  the  good  that  may  be  derived  from  the  stretching  process. 

It  may  be  approached  in  this  situation  from  without,  by  making  an 
incision  from  the  sigmoid  notch  to  the  angle  of  the  jaw.  The  parotid 
gland  is  turned  aside,  and  the  masseter  muscle  detached  from  the 
ramus  sufficiently  to  allow  the  application  of  a  trephine  at  a  point 
three  fourths  of  an  inch  behind  the  last  molar  tooth.  "When  the  but- 
ton of  bone  is  removed,  about  half  an  inch  of  the  nerve  can  be  iso- 
lated, exposed,  and  excised. 

The  nerve  may  be  exposed  in  its  course  through  the  body  of  the  jaw, 
by  raising  the  soft  parts,  by  means  of  an  incision  through  them,  about 
two  inches  in  length,  beginning  in  front  of  the  facial  artery.  After  the 
bone  is  thoroughly  exposed,  a  trephine  is  applied  in  two  or  more  situa- 
tions, and  the  bone  removed  down  to  the  canal,  when  the  intervening 
portions  may  be  chiseled  out,  and  the  whole  nerve  removed  ;  or  it  may 
be  excised  at  each  of  the  openings.     The  former  is  the  surer  method. 

It  may  also  be  divided  as  it  emerges  from  the  mental  foramen  by 
turning  the  lower  lip  outward  and  making  an  incision  about  an  inch 


OPERATIONS   OX   THE  NERVOUS  SYSTEM.  145 

in  length  at  the  junction  of  the  buccal  fold,  downward  three  fourths 
of  an  inch,  in  the  line  of  the  bicuspid  teeth,  when  a  careful  search  will 
"disclose  the  filaments  as  they  escape  from  the  opening.  Seize  them  with 
the  forceps,  draw  them  slowly  and  carefully  out,  and  cut  them  off. 

The  Lingual  Nerve. — This  may  be  reached  in  two  situations  :  1. 
As  it  passes  just  below  the  insertion  of  the  pterygo-maxillary  liga- 
ment.    2.   Beside  the  tongue  and  sublingual  gland. 

In  the  former,  the  mouth  is  opened  widely,  and  the  fold  of  mucous 
membrane  coveriug  the  ligament  is  readily  seen  behind  the  last  molar 
tooth.  The  nerve  can  be  felt  just  below  the  insertion  of  the  ligament, 
close  to  the  tooth.  Make  an  incision  backward  from  the  tooth  over 
the  course  of  the  nerve,  about  one  inch  in  length,  carefully  push  aside 
the  submucous  tissue,  and  the  nerve  will  appear  in  the  wound,  when 
it  can  be  raised  and  cut.  It  has  been  successfully  divided  on  several 
occasions  near  this  situation  by  entering  the  point  of  a  curved  bistoury, 
three  fourths  of  an  inch  behind,  and  below  the  last  molar,  cutting 
downward  and  outward  to  the  bone  in  an  imaginary  line  extending 
from  the  angle  of  the  jaw  to  the  last  molar  tooth. 

In  the  second  situation,  the  tongue  is  drawn  forward  and  to  the 
opposite  side,  and  an  incision  made  about  one  inch  in  length,  pai'allel 
with  the  tongue,  and  about  one  fourth  of  an  inch  from  the  attach- 
ment of  the  mucous  membrane  to  it ;  then  push  aside  the  submucous 
tissue,  and  the  nerve  will  be  readdy  seen. 

The  Facial  Nerve. — This  escapes  from  the  cranium  at  the  stylo- 
mastoid foramen,  passes  through  the  parotid  gland  and  divides  into 
the  temporo-facial  and  cervi co-facial  branches. 

Operation. — Make  an  incision  about  two  and  a  half  inches  in  length 
along  the  anterior  border  of  the  mastoid  process  and  sterno-mastoid 
muscle.  After  the  division  of  the  integument  and  fascia,  the  parotid 
gland  is  pushed  forward  with  the  handle  of  the  scalpel,  and  the  wound 
carefully  deepened  by  the  same  instrument.  At  about  three  fourths 
of  an  inch  from  the  surface  the  nerve  will  be  seen  passing  forward 
and  outward  from  its  foramen  of  exit.  At  about  a  fourth  of  an  inch 
to  the  inner  side  of  its  foramen  the  jugular  foramen  is  located  ;  for 
this  reason  caution  is  essential  to  avoid  wounding  the  jugular  vein. 
The  search  should  be  carefully  conducted  in  order  not  to  injure  the 
parotid  gland.  The  nerve  is  somewhat  deeply  situated,  being  separated 
from  the  bone  by  connective  tissue.  The  temporal  branch  can  be  di- 
vided where  it  crosses  the  condyle  of  the  jaw  through  an  oblique  incision 
extending  from  the  zygoma  to  the  posterior  border  of  its  ramus. 

Operations  on  Spinal  Nerves. — Great  Occipital  Nerve. — This  is  a 
large  branch  of  the  posterior  cervical  plexus  arising  from  the  internal 
division  of  the  second  nerve.  It  pierces  the  complexus  and  trapezius 
muscles  near  their  attachment  and  supplies  the  integument  as  far  for- 
ward as  the  vertex  of  tin;  skulL 

10 


146 


OPERATIVE   SURGERY. 


Operation.— Locate  the  occipital  protuberance  and  make  an  in- 
cision one  inch  and  a  half  in  length  downward,  forward,  and  outward 
at  its  outer  side,  beginning  about  an  inch  above  the  protuberance  ; 
carefully  separate  the  tissues  in  the  line  of  the  incision  and  the  nerve 
will  be  exposed  where  it  escapes  from  beneath  the  trapezius  muscle. 

Auricularis  Magnus  Nerve.—  This  nerve  is  one  of  the  ascending 
branches  of  the  cervical  plexus.  It  emerges  at  the  posterior  border  of 
the  sterno-mastoid  muscle  near  its  middle,  and  ascends  on  that  muscle 
to  the  lobule  of  the  ear. 

Operation.— Make  an  incision  two  inches  in  length  obliquely  up- 
ward and  backward,  its  center  corresponding  to  the  lower  extremity  of 
the  lobule  of  the  ear.  On  dividing  the  skin  and  fascia  the  nerve  will 
be  found  resting  on  the  sterno-mastoid  muscle,  from  which  it  can  be 
raised  with  a  hook  and  stretched  or  cut. 

Spinal  Accessory  Nerve. — This  nerve  is  excised  to  overcome  spas- 
modic actions  of  the  muscles  which  it  supplies  with  filaments.  It  can 
be  found  through  an  incision  made  behind  (De  Morgan,  Fig.  214),  or 

in  front  of  (Sands)  the  sterno- 
mastoid  muscle.  The  latter  is 
the  better  plan. 

Operation. — Make  an  incision 
three  inches  in  length  along  the 
anterior  border  of  the  sterno-mas- 
toid, beginning  close  to  the  mas- 
toid process ;  expose  the  sterno- 
mastoid,  pull  it  backward,  and 
the  nerve  will  be  found  beneath 

Fig.  214.— De  Morgan's  operation,  sc.  as  it  crosses  the  jugular  Vein, 
Sterno-cleido-mastoid  muscle,  n.  Spi-  which  should  be  Cautiously  avoid- 
nal  accessory  nerve,     s.  Splenius  mus-  ,         ,  ,     ,  ,,  , 

cle  ed  ;  close  and  dress  the  wound 

antiseptically. 

Branches  of  the  Brachial  Plexus. — It  may  become  necessary,  on 
account  of  a  severe  neuralgia  involving  the  branches  of  this  plexus,  or 
located  in  a  painful  stump,  to  excise  or  stretch  the  cords  near  their 
origin.  It  is  best  done  prior  to  its  division  into  its  three  terminal 
cords;  that  is,  where  only  two  cords  are  found.  Place  the  patient 
upon  the  back,  raise  the  shoulders,  and  turn  the  head  backward  and 
to  the  opposite  side.  The  course  of  the  external  jugular  is  determined 
by  pressure  just  above  the  clavicle.  Make  an  incision  along  the  pos- 
terior border  of  the  sterno-mastoid,  three  inches  in  length,  extending 
down  to  the  clavicle  ;  a  second  incision  of  the  same  length  is  now  made 
outward  from  this  point,  along  the  upper  border  of  the  clavicle,  care- 
fully avoiding  the  external  jugular  ;  turn  the  flap  upward  and  seek 
for  the  posterior  belly  of  the  omo-hyoid  ;  when  found,  draw  it  upward 
with  a  hook  or  ligature,  push  aside  the  loose  connective  tissue,  and  the 


OPERATIONS   ON   THE   NERVOUS   SYSTEM.  147 

two  cords  will  appear  located  above  and  to  the  outer  side  of  the  third 
portion  of  the  subclavian  artery,  which  should  be  carefully  avoided. 
The  inuer  cord  is  cautiously  hooked  up,  and  a  ligature  applied  to  it, 
by  which  it  can  be  raised  from  its  bed  and  divided  with  a  pair  of  scis- 
sors near  the  outer  border  of  the  scalenus  anticus  muscle,  being  careful 
to  avoid  the  muscle  and  the  phrenic  nerve.  If  gentle  traction  be 
made  upon  the  ligature,  the  distal  extremity  will  be  raised,  and  can 
be  again  divided  an  inch  or  so  from  the  point  of  the  first  section,  and 
removed.  The  second  or  outer  cord  is  then  divided  in  the  same 
manner. 

Musculo- Cutaneous  Nerve. — This  can  be  exposed  in  two  situations  : 
1.   As  it  escapes  from  the  axilla.     2.  Near  to  the  elbow  joint. 

Operation. — To  excise  it  in  the  first  situation,  carry  the  arm  from 
the  body  and  rotate  it  outward  ;  make  an  incision  three  inches  in 
length  along  the  outer  border  of  the  coraco-brachialis  muscle  ;  divide 
the  skin  and  fascia  on  a  director,  draw  the  muscle  inward,  and  the 
nerve  will  be  easily  found  at  its  outer  border. 

In  the  second  situation  it  is  found  by  making  an  incision  two  and 
one  half  inches  in  length,  between  the  biceps  and  the  supinator  longus, 
through  the  integument,  fascia,  and  aponeurosis  ;  separate  the  mus- 
cles and  the  nerve  will  be  readily  seen. 

Musculo- Spiral  Nerve. — This  can  be  exposed  in  two  situations  :  1. 
By  making  an  incision  about  four  inches  in  length,  between  the  outer 
border  of  the  triceps  and  the  brachialis  anticus  muscles,  beginning  it 
two  and  one  half  inches  above  the  external  condyle.  Divide  the  fas- 
cia on  a  director,  separate  the  connective  tissues  with  the  handle  of  a 
scalpel  or  by  the  finger,  and  the  nerve  will  be  easily  found.  2.  Make 
an  incision,  three  inches  in  length,  in  the  space  between  the  supinator 
longus  and  the  brachialis  anticus  muscles  ;  divide  the  fascia,  separate 
the  connective  tissue  beneath  it,  and  the  nerve  will  be  readily  exposed. 

Median  Nerve. — It  can  be  easily  exposed  in  its  course  along  the 
arm  and  lower  half  of  the  forearm  by  modifying  either  of  the  incis- 
ions for  ligaturing  the  brachial  to  correspond  to  the  relations  of  the 
nerve  to  that  vessel. 

In  the  forearm,  by  making  an  incision  about  three  inches  in  length, 
along  the  inner  border  of  the  tendon  of  the  flexor  carpi  radialis,  be- 
ginning about  two  inches  above  the  wrist-joint.  Divide  the  tissues  in 
the  usual  manner.  Separate  the  tendons  of  the  flexor  carpi  radialis 
and  palmaris  longus,  when  the  nerve  will  be  discovered  emerging  from 
beneath  the  fleshy  fibers  of  the  flexor  sublimis  digitorum. 

The  Radial  and  Ulnar  Nerves — like  the  median  in  the  arm — can 
be  reached  readily  through  the  same  incisions  employed  to  ligature 
tIi''  ressele  bearing  similar  names. 

Branches  of  the  Sacral  Plexus.— (S mil  Sri, die  Nerve. — This  is  best 
exposed  just  after  its  escape  from  beneath  the  lower  border  of  the 


148 


OPERATIVE  SURGERY. 


Fig.  215. — Great  sciatic  nerve  exposed, 
nerve,  gm.  Gluteus  maximus.  oh 
string  muscle — biceps  flexor  cruris. 


n,  n.  Sciatic 
Outer   ham- 


gluteus  maximus.  Place  the  patient  on  the  abdomen  and  make  an 
incision  three  or  four  inches  in  length,  beginning  at  the  gluteal  fold,  at 
a  point  midway  between  the  tuber-ischii  and  the  trochanter  major  (Fig. 
123,  a),  or  the  vertical  maybe  joined  by  a  short  horizontal  incision 
(Fig.  215) ;  divide  the  integument  and  fascia  on  a  director,  separate  the 

connective  tissue  with  the 
fingers  and  handle  of  the 
scalpel  down  to  the  nerve. 
It  can  then  be  stretched 
by  passing  one  or  two  fin- 
gers around  it,  and  mak- 
ing firm  and  stead}'  trac- 
tion upon  it.  Division  or 
excision  can  be  done  easily 
through  the  same  open- 
ing. The  wound  should 
be  carefully  closed  and 
dressed  under  antiseptic 
precautions. 

Bloodless  Stretching  of 
the  Sciatic. — Administer 
an  anaesthetic  and  place 
the  patient  on  the  back. 
Extend  the  leg  fully  on  the  thigh,  and  hold  the  pelvis  firmly.  Flex 
the  thigh  on  the  pelvis,  while  full  extension  of  the  leg  on  the  thigh 
is  continued.  This  causes  extreme  tension  of  the  muscles  and  other 
structures  on  the  posterior  surface  of  the  thigh,  thereby  stretching 
the  nerve.  The  manipulation  must  be  firmly  yet  cautiously  made  to 
attain  the  object,  and  at  the  same  time  not  tear  asunder  the  ham- 
string muscles. 

Results. — Obstinate  sciatica  has  been  relieved,  and  even  apparently 
cured,  by  this  simple  manipulation.  Not  infrequently  the  degree  of 
the  resulting  ecchymosis  indicated  rupture  of  the  muscular  struct- 
ures. 

Internal  Popliteal  Nerve. —  This  can  be  reached  by  the  same 
method  and  with  the  same  caution  as  the  popliteal  artery.  It  is, 
however,  less  deeply  situated  and  somewhat  nearer  the  center  of  the 
popliteal  space  than  the  vessels.  Extreme  caution  should  be  exercised 
in  operating  upon  it,  on  account  of  its  nearness  to  the  popliteal  vein, 
which  lies  beneath  it  and  to  its  inner  side. 

External  Popliteal  Nerve. — It  can  be  easily  reached  by  making  an 
incision,  two  or  three  inches  in  length,  along  the  inner  side  of  the 
tendon  of  the  biceps  cruris,  when  the  nerve  can  be  readily  found  be- 
neath the  fascia,  surrounded  by  fat. 

The  Small  Sciatic,  Anterior  and  Posterior  Tibial  Nerves  can  be 


OPERATIONS   OX   THE   NERVOUS   SYSTEM. 


149 


exposed  through  the  incisions  adopted  in  ligaturing  the  vessels  of  the 
same  names. 

Tlie  Plantar  Nerves. — These  are  the  terminal  branches  of  the  pos- 
terior tibial,  and  are  given  off  just  after  the  nerve  winds  around  the 
internal  malleolus.  They  can  be  exposed  by  making  an  incision  about 
three  inches  in  length,  beginning  just  in  front  of  the  center  of  a  line 
extending  from  the  anterior  border  of  the  internal  malleolus  to  the 
inner  tuberosity  of  the  os  calcis,  and  extended  forward  along  the  ex- 
ternal border  of  the  abductcr  pollicis.  If  the  space  between  the  short 
flexor  and  the  abductor  be  now  opened  at  the  posterior  portion,  the 
nerves  will  be  found  accompanied  by  the  arteries  of  similar  name. 

Perineal  Nerve. — This  may  be  exposed  in  the  perineum  of  the 
male  by  making  an  incision  along  the  rami  of  the  pubes  and  ischium 
in  the  same  manner  as  directed  for  ligaturing  the  pudic  artery  at  this 
situation.  In  the  female  perineum  the  nerve  may  be  exposed  either 
by  an  incision  made  without  or  within  the  vagina.  In  the  former, 
make  it  through  the  superficial  tissues,  about  three  inches  in  length, 
in  the  groove  between  the  labium  and  the  perineum,  just  inside  the 
rami  of  the  pubes  and  ischium.  The  nerve  is  surrounded  by  connect- 
ive tissue,  and  it  is  difficult  to  find  it  in  this  situation  ;  however,  if  the 
blade  of  the  knife  be  turned  inward  and  the  outer  coats  of  the  vagina 
be  divided  down  to  the  inner  one,  the  nerve  will  not  escape  section. 

It  is  more  easily  severed  from  within  the  vagina.  If  the  finger  be 
introduced  an  inch  or  more,  and  lateral  pressure  be  made,  the  nerve 
will  be  felt,  cord-like  in  character  and  sensitive  to  touch.  Make  a 
vertical  incision  through 
the  coats  of  the  vagina, 
and  the  nerve  will  be  ex- 
posed for  division  or  ex- 
cision. 

Branches  of  Lumbar 
Plexus. — Anterior  Cru- 
ral Nerve. — This  nerve 
is  the  largest  brancli  of 
the  lumbar  plexus,  and 
enters  the  thigh  beneath 
Poupart's  ligament, 
about  three  fourths  of  an 
inch  to  the  outer  side  of 
the  femoral  artery  (Fig. 
816). 

Operation. — Make  an 
incision  three  inches  in  length  directly  downward,  beginning  about  an 
inch  above  Poupart's  ligament,  in  the  line  of  the  nerve.  The  super- 
imposed layers  of  tissue  are  then  carefully  divided  on  a  director  down 


Fi(i.  216. — Anterior  crural  nerve  exposed, 
oral  artery,  n.  Anterior  crural  nerve, 
and  iliac  muscles.     *.  Sartoriua  muscle. 


/"• 


Fem- 
Psoaa 


150  OPERATIVE   SURGERY. 

to  the  groove  between  the  iliac  and  psoas  muscles,  in  which  it  rests. 
The  pulsations  of  the  femoral  artery  will  always  suggest  the  location 
of  the  nerve. 

The  Internal  or  Long  Saphenous  Nerve  is  given  off  from  the  ante- 
rior crural  and  supplies  the  inner  surface  of  the  leg.  It  is  accompa- 
nied by  a  vein  of  the  same  name  in  its  course  along  the  leg.  It  can  be 
reached  easily  in  many  situations,  but  practically,  however,  it  is  best 
exposed  at  the  inner  side  of  the  knee,  where  it  escapes  beneath  the  sar- 
torius,  and  at  the  middle  of  the  leg.  In  the  former  situation  recognize 
the  tendon  of  the  sartorius.  Press  upon  the  internal  saphenous  vein 
above  this  point  to  distend  it,  make  an  incision  two  inches  in  length 
close  to  and  parallel  with  the  vein,  draw  it  aside,  and  the  nerve  will 
be  found  emerging  from  beneath  the  tendons  of  the  sartorius  and 
gracilis.  At  the  middle  of  the  leg  make  an  incision  three  inches  in 
length,  parallel  with  the  properly  distended  vein,  which  should  then 
be  pulled  aside,  and  the  nerve  will  be  found  beneath  it. 

The  External  or  Short  Saphenous  Nerve  arises  from  the  internal 
popliteal,  escapes  between  the  heads  of  the  gastrocnemius,  pierces  the 
fascia  below  the  middle  of  the  leg  and  becomes  subcutaneous,  passes 
down  on  the  fibular  side  of  the  posterior  surface  to  the  malleolus,  ac- 
companied by  the  external  saphenous  vein.  Distend  the  vein  by  press- 
ure, make  an  incision  close  to  and  parallel  with  it,  near  the  border  of 
the  tendo  Achillis  ;  pull  the  vein  aside,  and  the  nerve  will  be  seen  be- 
neath. 

Suturing  of  Nerves. — This  is  a  procedure  of  modern  introduction, 
employed  to  unite  the  extremities  of  divided  nerves.  The  earlier  the 
attempt  is  made  the  better,  provided  the  tissues  surrounding  the  nerve 
be  not  inflamed.  Every  antiseptic  precaution  should  be  taken  ;  if 
possible,  it  should  be  done  under  the  douche  of  the  bichloride  solution. 

Operation. — A  free  incision  is  made  down  upon  the  ends  of  the 
nerves  to  be  united,  being  careful  not  to  disturb  unnecessarily  the 
surrounding  soft  parts.  The  extremities  are  refreshed  by  the  removal 
of  a  small  portion,  drawn  in  contact  with  each  other,  and  retained  in 
apposition  by  fine  antiseptic  catgut  passed  through  their  respective 
sheaths  and  tied.  It  is  wise,  owing  to  the  easy  absorption  of  the  cat- 
gut, to  re-enforce  it  by  one  or  two  horse-hair  or  fine  silk  asepticized 
sutures.  If  it  be  necessary,  a  fine  catgut  suture  can  be  passed  through 
the  nerve  structure  and  tied,  in  order  to  properly  oppose  and  maintain 
the  extremities.  If  the  distance  between  the  extremities  be  too  great 
to  allow  a  ready  apposition  of  them,  something  may  be  gained  by  mak- 
ing traction  on  them  and  by  the  relaxation  of  their  associated  soft 
parts.  If  a  sufficient  amount  of  the  nerve  be  present  to  admit  of  it, 
the  splicing  should  be  made  obliquely,  since  it  offers  a  better  oppor- 
tunity to  securely  unite  the  ends.  After  the  ends  are  united,  close  the 
wound,  dress  antiseptically,  and  place  the  part  in  an  easy  position. 


OPERATIONS   OX   TEXDOXS,   FASCLE,   AXD   MUSCLES. 


151 


Results. — The  results  thus  far  point  to  the  eutire  feasibility  of  the 
operation  ;  it  hastens  the  resumption  of  nerve  action  by  lessening  the 
distance  between  the  divided  extremities,  and  in  no  instance  has  it 
been  followed  by  neuritis  or  other  untoward  symptoms. 

Nerve  Transplantation. — Nerve  transplantation  is,  as  yet,  limited 
to  experimentation.  Sections  of  nerves  can  be  transplanted  and  union 
will  readily  take  place  ;  but  nervous  influence  is  not  quickly  estab- 
lished. Future  experimentation  in  this  line  will  no  doubt  secure 
some  great  practical  advance  in  the  surgery  of  the  nervous  system. 


CHAPTER   VII. 

OPERATIONS    ON  TEXDOXS,  FASCIAE,  AXD    MUSCLES. 

Tenotomy  consists  in  making  a  subcutaneous  division  of  the  ten- 
dons of  muscles  to  overcome  or  alleviate  a  deformity.  In  order  to 
accomplish  this  successfully,  the  exact  location  of 
the  offending  structure  must  be  known,  together 
with  its  important  contiguous  vessels,  nerves,  etc. 
Many  of  the  large  tendons  are  easily  located  by 
their  natural  prominence.  Others  that  ordinarily 
lie  concealed  become  apparent  if  contraction  has 
occurred,  and  still  more  conspicuous  if  they  be 
placed  upon  the  stretch.  The  principles  governing 
tenotomy  should  be  well  considered  ere  a  tendon 
be  divided,  otherwise  an  expedient  of  great  good 
becomes  mischievous  and  even  destructive  in  its 
results.  Muscles  and  fascias,  either  singly  or  con- 
jointly, are  also  the  direct  causes  of,  or  may  be  in- 
directly connected  in,  causing  deformities.  They, 
too,  are  amenable  to  a  similar  treatment. 

The  instruments  employed  are  few  in  number 
and  simple  in  character.  Fig.  217  represents  the 
tenotomes  used  by  Prof.  L.  A.  Sayre.  They  are  excellenl  instru- 
ments for  the  purpose.  Fig.  218  represents  the  ordinary  tenotome 
found  in  the  pocket-cases  of  the  day.  It  is  too  fragile  to  be  safely  em- 
ployed in  the  division  of  tissues  requiring  any  outlay  of  force.  A 
detailed  description  of  either  is  unnecessary,  since  they  can  be  ordered 
from  the  instrument-maker  by  simply  naming  the  designer. 

The  blade  of  the  tenotome  used  for  dividing  Easciae  and  muscles 
(Fig.  'i\'>)  is  of  necessity  much  longer  than  either  of  the  former  ;  the 


Fig.  217.— Teno- 
tomes. 


152 


OPERATIVE  SURGERY, 


principl 
cocaine 


Fig.  218. — Tenotome. 


es  embodied  in  it,  however,  are  substantially  the  same.  A 
solution  may  be  injected  near  the  point  of  division.  An  ob- 
servance of  the  following  simple  rules  will  obviate  the  pos- 
sibility of  doing  violence  to  other  than  the  tissues  directly 
concerned  in  the  operation  :  1.  Mark  the  handle  to  indicate 
the  direction  toward  which  the  cutting  edge  looks.  2.  Care- 
fully note  the  length  of  the  blade,  that  it  may  be  inserted 
only  far  enough  to  divide  the  contracted  tissues.  3.  Place 
the  structure  to  be  divided  upon  the  stretch  (Fig.  220). 
Pinch  up,  or  press  aside  the  skin  over  the  part  to  be  cut,  so 
that  when  it  is  released,  after  the  completion  of  the  opera- 
tion, the  opening  will  not  correspond  to  the  divided  tissues. 
4.  The  blade  should  be  made  aseptic  before  being  used.  5. 
Pass  the  knife-blade  from  important  vessels  and  nerves.  6. 
Insert  the  blade  on  the  flat,  close  to  the  surface  of  the  tissue 
to  be  divided  ;  turn  the  edge  toward  it,  and  carefully  sever 
it  by  a  guarded  sawing  motion,  aided  by  pressing  the  tendon 
upon  the  cutting  surface  of  the  knife.  If  unguarded  force 
be  used,  the  tendon  and  its  superimposed  tissues  may  be  di- 
vided, which  will  seriously  complicate  the  recovery.  7. 
Withdraw  the  blade  upon  the  flat,  follow  it  by  firm  pressure 
upon  the  parts  with  the  thumb,  which  should  finally  rest 


Eig.  219.— 
Fasciatome. 


Fig.  220. — Dividing  a  tendon. 


OPERATIONS  ON   TENDONS,   FASCLE,   AND   MUSCLES.  153 

upon  the  incision  ;  this  will  press  out  all  blood  and  exclude  the  air. 
8.  Seal  the  wound  carefully  with  adhesive  plaster  or  collodion  ;  or 
stitch  it  with  asepticized  silk,  and  apply  the  antiseptic  dressing.  9. 
Kectifv  the  deformity  and  confine  the  part  to  which  the  tendon  is 
attached  until  repair  shall  have  commenced.  10.  Avoid  the  division 
of  a  tendon  as  it  passes  through  its  sheath,  if  possible.  11.  Divide 
the  offending  tissue  at  the  point  of  greatest  forced  prominence,  pro- 
vided it  be  consistent  with  its  relation  to  important  structures.  If 
reflex  spasm  results  from  "point  pressure,"  the  tendon  should  be 
divided,  and  at  the  pressure-point  inciting  the  reflex  action.  Cocaine 
injections  act  admirably. 

Tenotomy — Upper  Extremities.  —  The  tendons  of  the  flexor  sub- 
limit -And  flexor  profundus  digitorum  may  be  divided  by  a  transverse, 
subcutaneous  incision  carried  through  them  down  to  the  bone  at  about 
the  middle  of  the  first  row  of  anatomical  phalanges.  Antiseptic  pre- 
cautions should  be  observed  carefully  in  this  instance,  otherwise  severe 
inflammation  of  the  sheaths  of  the  tendons  may  follow.  After  the 
division  of  the  tendons  reduce  the  deformity  and  keep  the  parts  quiet 
for  five  or  six  days,  till  the  danger  from  inflammation  has  subsided, 
when  they  may  be  cautiously  moved. 

Extensor  Communis  Digitorum. — The  tendons  of  this  muscle  can 
be  readily  divided  as  they  pass  along  the  carpus  or  upon  the  dorsum 
of  the  phalanges.  In  the  former  instance,  pinch  up  the  skin,  pass 
the  knife  beneath  the  tendon  as  before  directed,  and  cut  toward  the 
surface.  They  may  be  divided  by  passing  the  blade  above  the  tendons 
and  cutting  down  upon  the  bone.  On  the  dorsum  of  the  phalanges 
the  blade  should  be  passed  beneath  the  skin,  and  the  tendons  divided 
upon  the  bone.  In  the  division  of  the  tendons  of  both  flexor  and  ex- 
tensor muscles,  the  joints  and  palm  of  the  hand  above  the  transverse 
line  should  be  avoided,  also  the  course  of  the  vessels  and  the  spaces 
between  the  metacarpal  bones. 

The  Extensor  Primi  Internodii,  Secundi  Internodii,  and  Ossis 
Metacarpi  Pollicis  Tendons  can  readily  be  made  prominent  by  forcible 
extension  of  the  thumb  in  the  living  subject,  with  the  forearm  mid- 
way between  supination  and  pronation.  The  primi  internodii  and 
ossis  metacarpi  pollicis  tendons  form  the  inner  boundary  of  the  "  snuff- 
box," at  the  apex  of  the  styloid  process  of  the  radius,  the  ossis  meta- 
carpi pollicis  being  the  innermost  of  the  two.  The  tendon  of  the 
extensor  secundi  forms  its  outer  boundary.  They  can  be  divided  in 
this  situation  by  first  making  them  as  prominenl  as  possible,  then  in- 
troducing the  knife  beneath  from  the  anterior  surface  of  the  wrist 
and  cutting  toward  the  integument.  The  radial  artery  is  to  be  avoided 
a- it  passes  beneath  them,  and  likewise  the  radicle  of  the  radial  vein 
as  it  crosses  the  intervening  space. 

Flexor  Carpi  Radialis.— The  tendon  of  this  muscle  is  Bituated 


154 


OPERATIVE  SURGERY. 


immediately  to  the  inner  side  of  the  radial  artery,  at  the  lower  third 
of  the  forearm,  and  can  be  readily  divided  by  passing  the  knife  from 
the  artery  beneath  the  tendon. 

Flexor  Carpi  Ulnaris. — This  is  the  most  internal  tendon  on  the 
anterior  surface  of  the  forearm,  and  has  the  ulnar  artery  at  the  outer 
border.  It  can  be  easily  cut  by  passing  the  knife  beneath  it,  from 
without,  inward. 

Biceps  Muscle  at  the  Forearm.— The  tendon  of  insertion  of  this 
muscle  may  be  divided  either  above  or  below  the  giving  off  the  bicipi- 
tal fascia.  The  former  is  the  safer.  Make  the  veins  in  the  region 
prominent  by  constricting  the  arm  above,  extend  the  forearm  to  make 
the  tendon  prominent  and  tense  ;  enter  the  knife  at  its  inner  border, 
pass  it  cautiously  between  it  and  the  brachial  artery,  and  cut  upward, 
being  careful  not  to  injure  the  distended  veins. 

Tenotomy — Lower  Extremities. — Tibialis  Posticus. — The  tendon 
of  this  muscle  is  intimately  associated  with  the  deformity  of  talipes 
varus.  It  runs  along  the  inner  border  of  the  tibia,  behind  the  inter- 
nal malleolus,  in  a  separate  sheath,  being  the  innermost  tendon  at 
this  situation  ;  after  leaving  the  internal  malleolus,  it  passes  beneath 
the  calcaneo-scaphoid  articulation  to  its  insertions. 

In  the  normal  foot  it  lies  well  concealed  within  its  closely  fitting 
groove  ;  but  it  can  be  readily  outlined  between  the  tip  of  the  malleolus 
and  the  calcaneo-scaphoid  articulation. 

In  talipes  varus  it  is  raised  from  its  groove  and  becomes  more 
prominent  above  the  tip  of  the  internal  malleolus,  as  well  as  below  it. 
It  can  be  divided  in  either  situation,  but  it  is  better  done  at  a  point 
about  an  inch  and  a  half  above  the  tip  of  the  malleolus  in  the  adult, 
and  one  inch  in  the  child  or  infant.  The  tendon  is  made  tense  by 
strongly  abducting  the  foot,  and  the  knife  is  passed  with  the  usual 
precautions  between  the  posterior  border  of  the  tibia  and  the  tendon  ; 
the  division  is  made  by  cutting  outward. 

The  section  between  the  tip  of  the  malleolus  and  the  calcaneo- 
scaphoid  articulation  is  not  advised,  on  account  of  the  contiguity  of 
the  ankle-joint  and  the  internal  plantar  artery  ;  if,  however,  it  be 
thought  advisable  to  operate  at  this  situation,  the  foot  should  be 
strongly  abducted,  and  the  point  of  the  tenotome  carefully  insinuated 
beneath  the  tendon,  and  between  it  and  the  internal  plantar  artery ; 
the  handle  is  then  depressed  so  as  to  carry  the  point  away  from  the 
joint,  and  the  section  made  from  within  outward. 

Flexor  Longus  Digitorum. — The  tendons  of  this  muscle  are  some- 
times productive  of  contraction  of  the  toes,  after  the  correction  of  the 
deformity  of  the  tarsus  caused  by  the  tibialis  posticus.  It  lies  imme- 
diately posterior  to  the  tendon  of  that  muscle,  behind  the  internal 
malleolus,  and  is  often  divided  by  the  same  cut  which  severs  the  tendon 
of  the  tibialis  posticus.     It  can,  however,  be  divided  independently. 


OPERATIONS   ON   TENDONS,   FASCLE,   AND    MUSCLES.  155 

If,  after  the  division  of  the  posticus  tendon,  the  influence  of  the 
flexor  longus  digitorum  be  objectionable,  it  may  be  divided  by  intro- 
ducing the  tenotome  beneath  it  through  the  same  incision,  and  cut- 
ting toward  the  surface  as  before.  The  posterior  tibial  artery  and  its 
vense  comites,  which  in  the  adult  are  often  varicose  in  this  situation, 
must  be  carefully  avoided  by  pressing  them  outward  with  the  finger. 
If  from  contraction  of  the  toes,  unassociated  with  deformity  due  to 
the  tibialis  posticus,  it  be  deemed  advisable  to  sever  its  tendon,  the 
posterior  tibial  vessels  must  be  first  detected,  pushed  outward  by  the 
thumb,  which  should  then  be  pressed  firmly  between  them  and  the 
tendons  at  the  inner  side  ;  pass  the  tenotome  perpendicularly  through 
the  integument,  midway  between  the  posterior  margin  of  the  tibia 
and  the  end  of  the  thumb  ;  carefully  insinuate  it  between  the  ten- 
dons of  the  posticus  and  the  flexor  longus  digitorum  down  to  the 
bone,  turn  the  edge  upward,  and  carefully  divide  it  toward  the  surface. 

Flexor  Longus  Pollici*. — It  may  become  necessary  to  divide  the 
tendon  of  this  muscle,  on  account  of  the  crippled  action  of  the  foot  in 
walking,  dependent  upon  undue  flexion  of  the  great  toe. 

The  toe  should  be  forcibly  extended,  and  the  knife  carefully  in- 
serted beneath  it  at  the  point  of  its  greatest  prominence,  which  will 
be  at  the  anterior  and  inner  side  of  the  foot.  The  instrument  must 
always  be  passed  from  the  internal  plantar  artery. 

The  Tenclo  Achillis  is  the  most  prominent  tendon  of  the  human 
system,  and  should  be  divided  at  its  narrowest  portion.  The  posterior 
tibial  artery  is  at  the  front  and  inner  side,  but  sufficiently  remote  to 
be  secure,  if  ordinary  care  be  exercised.  The  short  saphenous  vein 
lies  superficially  and  closely  to  its  outer  border. 

It  can  be  readily  divided  if  the  foot  be  forcibly  flexed,  to  render  it 
tense  ;  pinch  up  the  skin,  push  it  outward  to  protect  the  vein,  enter 
the  knife  beneath  it  from  within  outward,  turn  the  edge  toward  the 
tendon  and  carefully  sever  it  with  a  sawing  motion  while  the  foot  is 
firmly  flexed  and  the  tendon  pressed  upon  the  edge  of  the  knife  by 
the  finger.  Great  care  is  necessary,  else  a  sudden  giving  way  of  the 
tendon  may  cause  the  knife  to  sever  the  superimposed  tissues.  All 
the  precautions  enjoined  in  tenotomy  should  be  carefully  observed  in 
this  instance. 

PeroncuH  Longus  and  Brcvi*. — Their  tendons  pass  in  a  common 
groove  behind  the  external  malleolus,  and  are  inclosed  by  the  same 
Bheath,  the  hitter  passing  the  most  unteriorly.  It  loaves  its  fellow 
after  passing  behind  the  malleolus,  and  is  inserted  into  the  base  of  the 
metatarsal  bone  of  the  little  toe  on  the  outer  side.  The  longus,  after 
passing  behind  the  malleolus,  gains  the  sole  of  the  foot,  enters  the 
calcaneocuboid  groove,  mid  is  inserted  into  the  base  of  the  metatarsal 
bone  of  the  great  toe  ;it  its  outer  side.  The  tendon  of  either  may  he 
divided  in  two  situations  :  1.   A.boul  one  and  one  half  inch  above  the 


156 


OPERATIVE   SURGERY. 


tip  of  the  malleolus.  2.  Three  fourths  of  an  inch  in  front  of  it. 
They  are  commonly  divided  in  the  former  situation.  They  can  be 
severed  connectedly  or  singly  in  either  situation. 

If  it  be  decided  to  sever  both  simultaneously  above  the  malleolus, 
seek  the  anterior  and  external  border  of  the  fibula,  about  an  inch  and 
a  half  above  its  tip,  pass  the  knife  between  the  bone  and  tendons,  turn 
the  edge  outward  and  cut  toward  the  surface.  The  short  saphenous 
vein  should  be  pushed  inward  to  avoid  injury. 

If  either  is  to  be  divided  separately,  push  the  integument  back- 
ward with  the  thumb,  to  protect  the  vein,  then  push  the  thumb  firmly 
down  to  the  bone  behind  the  tendons  ;  pass  the  tenotome  perpendicu- 
larly midway  between  the  end  of  the  thumb  and  the  external  border 
of  the  fibula,  carefully  insinuate  it  between  the  tendons,  after  which 
it  is  passed  outward  or  inward,  as  the  case  may  be,  beneath  the  ten- 
don to  be  severed,  the  edge  turned  upward,  and  the  division  made  as 
in  the  preceding  instances. 

If  the  division  be  made  below  the  malleolus,  make  the  tendons 
tense,  enter  the  knife  about  one  half  or  three  fourths  of  an  inch  in 
front  of  the  tip  of  the  malleolus,  between  the  tendons,  when  either  or 
both  may  be  divided. 

Tibialis  Anticus. — This  muscle,  like  the  posticus,  is  of  importance 
in  connection  with  the  deformity  of  talipes  varus. 

It  is  the  innermost  tendon  of  the  leg  and  foot  on  its  anterior  sur- 
face, and  can  be  easily  outlined  unless  the  foot  be  fat  and  chubby, 
when  some  difficulty  may  be  experienced. 

In  well-marked  cases  of  talipes  varus  it  is  displaced  considerably  to 
the  inner  side,  and,  if  the  foot  be  abducted,  will  become  quite  promi- 
nent. It  is  best  divided  about  one  inch  above  its  insertion  into  the 
internal  cuneiform  bone.  Make  the  tendon  tense,  pass  the  knife  from 
without  inward,  to  avoid  the  dorsalis  pedis  artery. 

Extensor  Proprius  Pollicis. — As  it  passes  across  the  dorsum  of  the 
foot,  it  can,  like  the.  preceding,  be  quite  easily  distinguished.  It  may 
become  necessary  to  divide  it  after  the  division  of  the  extensors  of  the 
tarsus,  on  account  of  its  causing  undue  extension  of  the  great  toe. 
The  toe  should  be  forcibly  flexed,  and  the  tenotome  carried  beneath  it 
from  without  inward,  to  avoid  the  dorsalis  pedis  vessels. 

Extensor  Longus  Digitorum. — The  tendons  of  this  muscle  may 
not  only  cause  an  obstinate  extension  of  the  toes,  but  aid  in  maintain- 
ing the  tarsus  in  a  state  of  forced  flexion.  They  can  be  divided  sepa- 
rately, as  they  pass  along  the  dorsum  of  the  foot,  provided  either 
require  it.  If  all  be  cut  at  once,  it  is  done  by  flexing  the  toes,  enter- 
ing the  knife  beneath  them,  a  little  below  the  bend  of  the  ankle,  from 
within  outward,  to  avoid  the  dorsalis  pedis  vessels. 

Peroneus  Tertius. — This  may  be  divided  together  with  the  extensor 
longus  digitorum,  of  which  it  is  a  part  ;  or  it  can  be  done  separately 


OPERATIONS   OX   TEXDOXS,   FASCLE,   AXD   MUSCLES.  157 

before  its  insertion  into  the  dorsum  of  the  metatarsal  bone  of  the  little 
toe,  by  extending  the  tarsus,  and  passing  the  knife  beneath  it,  from 
without  inward.  It  is  the  most  external  tendon  on  the  dorsum  of  the 
foot,  in  front  of  the  external  malleolus. 

Biceps  of  the  Leg. — This  tendon  forms  the  external  hamstring, 
and  is  inserted  into  the  head  of  the  fibula  and  the  outer  tuberosity  of 
the  tibia.  The  external  popliteal  nerve  is  located  immediately  at  its 
inner  side.  To  divide  it,  the  leg  should  be  extended,  and  the  tenot- 
ome passed  from  within  outward,  beneath  the  tendon  about  an  inch 
and  a  half  above  the  head  of  the  fibula. 

The  inner  hamstring  tendons  are  the  semi-tendinosus,  semi-mem- 
branosus,  gracilis,  and  sartorius  ;  the  two  first,  however,  are  the  ones 
principally  concerned.  The  tendon  of  the  semi-tendinosus  is  felt  as 
the  longest,  smallest,  and  nearest  to  the  median  line  of  the  popliteal 
space  ;  that  of  the  semi-membranosus  is  internal  to  it,  somewhat  less 
superficial,  and  runs  parallel  with  it.  Either  of  these  tendons  can  be 
divided  by  extending  the  leg  to  make  it  tense,  and  entering  the  knife 
beneath  and  from  the  outer  side,  at  the  most  prominent  portion,  and 
cutting  toward  the  surface.  Their  division  to  relieve  forced  flexion 
of  the  leg  will  not  always  admit  of  complete  extension,  due,  among 
other  things,  to  the  contraction  of  the  heads  of  the  gastrocnemius, 
which  are  inserted  into  the  condyles  of  the  femur.  The  forced  exten- 
sion of  the  leg  under  these  circumstances  often  causes  a  tearing  asun- 
der of  the  attachments  of  this  muscle,  especially  in  the  inner  head, 
which  is  larger,  stronger,  and  inserted  higher  than  the  external.  The 
hemorrhage  resulting  therefrom  may  be  severe  enough  to  infiltrate  the 
calf  of  the  limb,  even  extending  throughout  the  popliteal  space.  The 
liability  to  this  rupture  and  consecpient  bleeding  may  be  lessened,  if 
not  obviated,  by  first  dividing  the  tendo  Achillis  ;  or,  what  is  per- 
haps better,  by  first  dividing  the  hamstring  tendons,  when,  if,  on  at- 
tempting to  straighten  the  limb,  the  foot  becomes  extended,  the  tendo 
Achillis  can  then  be  divided. 

Gracilis  and  Sartorius. — They  may  be  divided,  after  forcible  ex- 
tension of  the  leg.  Pass  the  tenotome  close  at  the  inner  side  of  the 
tendon  of  the  semi-membranosus,  between  it  and  the  gracilis,  depress 
the  handle  outward  or  inward,  as  the  case  may  be,  and  divide  these 
structures  toward  the  skin. 

The  Quadriceps  Extensor  Tendon  may  be  divided  above  the  pa- 
tella by  making  an  incision  down  to  the  tendon  parallel  with  the 
base  of  the  patella  ;  enter  the  point  of  the  knife  above  it  cautiously, 
and  with  a  sawing  motion  divide  the  tendon.  A  careful  and  continu- 
ous attempt  should  be  made  to  flex  the  leg  while  the  tendon  is  being 
cut,  that  its  deepesl    fibers    may  be  ruptured,  thus  avoiding,  a-'  far  as 

possible,  entering  the  synovial  extension  of  the  knee-joint,  which  lies 
beneath  it.     However,  the'  limbshould  not  be  flexed  farther  than  is 


158  OPERATIVE   SURGERY. 

necessary  for  this  purpose,  and  after  the  division  should  be  placed  in 
a  comfortable  position  till  repair  is  well  advanced. 

Pectineus.— This  muscle,  which  acts  as  a  flexor  and  adductor  of 
the  thigh,  may  require  division  on  account  of  malposition  of  the  limb. 
The  pelvis  is  steadied,  thigh  extended  and  abducted,  which  causes  the 
fibers  to  become  tense  and  prominent.  A  long-bladed  tenotome  is 
then  introduced  at  the  outer  border,  about  an  inch  below  its  origin, 
and  carried  inward  and  upward,  till  the  division  is  complete.  The 
internal  circumflex  artery,  which  runs  between  the  psoas  magnus  and 
the  outer  border  of  the  pectineus,  is  the  only  vessel  of  any  size  exposed 
to  injury.  The  danger  to  this  is  obscure,  unless  it  arises  high'er  than 
usual.  If  the  division  be  made  downward  and  inward  the  femoral 
vessels  will  be  less  exposed  than  when  made  in  the  opposite  direction. 

The  Adductor  Longus  is  situated  farther  to  the  inner  side  of  the 
thigh  than  the  preceding,  forming  the  inner  border  of  Scarpa's  tri- 
angle. It  is,  however,  located  on  about  the  same  plane  as  the  pecti- 
neus. It  is  tendinous  at  its  origin  from  the  pubes,  and  can  be  easily 
divided,  when  made  tense,  by  passing  the  knife  beneath  its  outer  bor- 
der, and  cutting  upward  and  inward. 

The  Tensor  Vagince  Femoris  can  be  severed  without  difficulty  by 
introducing  a  long-bladed  tenotome  beneath  it,  from  either  border  of 
the  muscle,  about  an  inch  below  its  origin,  and  cutting  toward  the 
surface. 

The  Sartorius  forms  the  outer  boundary  of  Scarpa's  triangle,  and 
can  be  divided  by  making  its  fibers  tense,  by  strong  abduction  ;  then 
introducing  a  long  tenotome  beneath  it,  at  its  inner  border,  two 
or  three  inches  from  its  origin,  and  cutting  upward  toward  the  sur- 
face. 

Muscles  of  the  Trunk. — The  Multifidus  Spince  lies  on  either  side 
of  the  spinous  processes,  in  the  groove  formed  by  the  spines  and  trans- 
verse processes,  from  the  sacrum  to  the  axis.  This  muscle  is  quite  su- 
perficial in  the  sacral  region,  opposite  to  the  posterior  superior  spinous 
process  of  the  ilium.  Eaise  a  fold  of  skin  parallel  with  the  long  axis 
of  the  muscle  ;  pass  a  long-bladed  tenotome  from  the  spine  outward 
to  the  outer  border  of  the  muscle,  and  cut  toward  the  spine. 

Latissimus  Dorsi. — The  tendon  of  this  muscle  may  be  divided 
separately  at  the  lower  border  of  the  axilla,  or  conjointly  with  that  of 
the  teres  major,  a  short  distance  below  their  insertion  into  the  hu- 
merus. 

In  either  instance  the  arm  is  forcibly  raised  to  render  them  tense 
and  prominent,  and  a  long,  narrow-bladed  tenotome  is  inserted  along 
the  anterior  border,  and  they  are  carefully  severed  by  a  sawing  motion. 

It  may  likewise  be  divided  at  the  lower  angle  of  the  scapula. 
Make  the  muscle  tense  as  before,  pass  a  long,  strong  tenotome  beneath 
it,  and  cut  carefully  outward  ;  close  the  opening  with  a  compress. 


OPERATIONS   ON   TENDONS,   FASCIA,   AND   MUSCLES.  159 

The  Erector  Spines  forms  the  principal  portion  of  the  muscular 
prominence  on  either  side  of  the  spine  to  be  seen  in  the  lumbar  re- 
gion. This  is  a  thick,  strong  muscle,  which  arises  from  the  sacrum 
and  contiguous  structures,  and  divides  at  the  lower  border  of  the  last 
rib  into  the  longissimus  dorsi  and  sacro-lumbalis,  which  are  inserted 
into  the  angles  of  the  ribs  and  the  transverse  processes  of  the  dorsal 
vertebra?.  The  erector  spina?  can  be  divided  by  a  long  tenotome 
passed  from  within  outward,  to  the  outer  border  of  the  muscle,  just 
below  the  last  rib,  and  carried  downward  and  inward  toward  the 
spine. 

Trapezius. — This  is  a  muscle  possessing  an  extensive  origin.  The 
portion  which  arises  from  the  inner  third  of  the  superior  curved  line 
of  the  occipital  bone  is  often  divided,  on  account  of  abnormal  devi- 
ations of  the  head. 

This  is  readily  accomplished  by  making  the  muscle  tense,  and 
severing  it  with  a  tenotome  entered  beneath  it,  just  below  the  occipi- 
tal protuberance,  the  edge  turned  toward  the  integument. 

Stemo-cleido-mastoid. — Division  of  this  muscle  is  often  necessary 
in  cases  of  wryneck  dependent  upon  abnormal  muscular  force.  It 
is  divided  at  its  lower  extremity,  either  at  its  sternal  or  its  clavicular 
attachment  ;  often  at  both.  For  the  division  at  either,  the  muscle  is 
put  on  the  stretch  by  turning  the  head,  and  the  blunt-pointed  teno- 
tome passed  beneath  it  from  the  outer  side,  about  half  an  inch  above 
its  insertion,  and  divided  toward  the  surface.  The  division  of  the 
clavicular  portion  may  be  ample  to  correct  the  deformity  ;  if  not,  the 
sternal  portion  should  be  severed  in  the  same  manner.  It  is  necessary 
to  closely  hug  the  under  surface  of  the  portions  to  be  divided,  else  the 
deep-seated  and  important  vessels  may  be  injured.  It  is  not  safe  to 
attempt  a  subcutaneous  section  of  the  muscle  above  this  point,  on 
account  of  its  relation  to  the  common  carotid  artery  and  the  internal 
jugular  vein. 

Plantar  Fascia. — This  tissue  is  an  exceeding  dense,  white  fibrous 
membrane  of  great  strength,  with  the  fibers  arranged  longitudinally. 
It  is  divided  into  three  portions,  the  middle  and  two  lateral.  The 
former  is  the  one  especially  concerned  in  those  deformities  requiring 
division.  It  is  narrow  behind  and  attached  to  the  inner  tubercle  of 
the  os  calcis  ;  broader  and  thinner  in  front,  and  divides  into  five  pro- 
's opposite  the  middle  of  the  metatarsal  bones,  being  one  for  each 
of  the  toes.  Each  of  these  processes  divides  opposite  the  metatarso- 
phalangeal articulations  into  two  slips,  which  embrace  the  sides  of  the 
llcxor  tendons,  and  are  inserted  into  the  sides  of  the  metatarsal  bones 
and  the  transverse  metatarsal  ligament.  It  likewise  soul-:  prolonga- 
tions between  the  groups  of  the  plantar  muscles.  This  fascia  serves 
the  important  function  of  assisting  in  maintaining  the  integrity  of  the 
plantar  arch. 


160 


OPERATIVE   SURGERY. 


It  is  divided  by  placing  it  upon  the  stretch,  and  passing  a  teno- 
tome beneath  the  inner  border  of  the  most  prominent  portion,  and 
cutting  toward  the  sole.  The  deformity  is  then  overcome  as  much  as 
is  practicable,  and  the  foot  is  placed  and  fixed  in  the  corrected  po- 
sition. 

Palmar  Fascia.— Like  the  plantar  fascia,  this  is  divided  into  three 
portions— two  outer  and  a  middle  part,  the  middle  division  being  one 
of  special  significance.  It  is  narrow  above,  and  attached  to  the  lower 
border  of  the  annular  ligament  ;  below  it  is  broad  and  thinner,  and 
opposite  the  heads  of  the  metacarpal  bones  divides  into  four  slips,  one 
for  each  finger.     Each  slip  subsequently  subdivides  into  two  processes, 


Fig.  221. — Fascial  contractions,     a.  Fascial  contractions,     b.  Flexor  tendons. 

which  inclose  the  tendons  of  the  flexor  muscles,  and  are  attached 
to  the  sides  of  the  first  phalanx,  and  to  the  glenoid  ligament,  and 

extends  upward  over  the  flexor  tendons 
nearly  to  the  tip  of  the  finger.  This  fascia 
is  intimately  connected  with  the  integu- 
ment of  the  palm,  and  sends  vertical  septa 
between  its  muscles.  From  various  causes 
it  may  undergo  structural  changes,  which 
result  in  contractions  of  the  fingers  on  the 
palm,  as  well  as  shortening  of  the  palm  it- 
self. The  anatomical  arrangement  of  the 
fascia  fully  explains  the  mechanism  of  the 
deformity. 

Dupuytren's  Contraction. — This  deform- 
ity depends  upon  the  contraction  of  the 
prolongations  of  fascia  of  the  palm,  con- 
nected with  the  digits  ;  the  morbid  process 
more  frequently  manifests  itself  in  the 
ring  and  little  fingers,  causing  them  oft- 
times  to  become  opposed  to  the  palmar 
surface  of  the  hand. 
Operation.—  Anaesthetize  the  patient  ;  render  the  restricting  bands 
tense  by  a  firm  extension  of  the  affected  digits,  and  then,  under  anti- 


Fig.  222. — Transverse  incisions 
tor  Dupuytren's  contraction. 


OPERATIONS   OX   TENDONS,   FASCLffi,   AND   MUSCLES.  161 

septic  precautions,  divide  the  restraining  bands  at  short  intervals, 
subcutaneously,  with  a  narrow-bladed  knife,  its  edge  being  directed 
from  the  surface  of  the  palm.  When  sufficiently  liberated  the  digits 
can  be  freely  extended,  in  which  position  they  are  to  be  confined  by 
dorsal  splints  until  repair  is  completed.  Passive  motion  and  forcible 
extension  until  the  tendency  to  contraction  is  overcome,  comprise  the 
important  elements  of  the  after-treatment.  Goyraud  made  longitu- 
dinal incisions  over  the  tense  digital  prolongations  of  fascia,  dissected 
the  integument  from  them,  after  which  they  were  divided  sufficiently 
to  admit  of  extension  of  the  digits  ;  the  integumentary  incisions  were 
closed  and  the  fingers  confined  in  a.  straight  position  until  healed.  His 
success  Avas  gratifying. 

Fallacy. — This  deformity  may  be  confounded  with'  that  dependent 
upon  contraction  of  the  flexor  tendons..  An  examination  of  Fig.  221 
will  enable  the  surgeon  to  make  a  clear  distinction  between  the  two 
conditions. 

The  fascia  in  other  situations  may  become  contracted,  as  the  fascia 
lata,  at  its  upper  or  lower  extremities.  Whenever  these  contractions 
cause  a  persistent  deformity  they  should  be  divided,  and  upon  the 
same  principles  as  like  tissues  in  other  portions  of  the  body.  The 
employment  of  an  anaesthetic  is  advisable  in  tenotomy,  especially 
when  the  section  is  to  be  extensive,,  or  contiguous  to  important  struct- 
ures.    In  all  instances  antiseptic  precautions  should  be  taken. 

Tendon  Suturing. — The  uniting  of  divided  tendons  by  catgut  or 
by  fine  silver  wire  is  an  accomplished  fact.  Hereafter  the  practical 
surgeon,  instead  of  assigning  as  a  reason  for  the  permanent  immobility 
of  an  extremity,  that  "  The  tendon  was  cut,"  should  first  make  an 
earnest  effort  to  unite  its  extremities.  The  espeeial  functions  of  the 
divided  tendons  can  be  determined  by  causing  movements  of  the  car- 
pus and  fingers,  independently  of  each  other,  and  watching  the  effects 
of  these  movements  on  the  distal  extremities  of  the  divided  tendons. 
Some  difficulty  is  often  experienced  in  finding  the  respective  ends  of 
the  severed  tendons,  since  they — especially  the  ends  connected  with 
the  muscular  belly — are  notably  drawn  into  their  sheaths. 

Operation. — Under  full  antiseptic  precautions,  flex  the  part  so  as 
to  produce  the  greatest  relaxation  of  the  muscles  associated  with  the 
divided  tendons  ;  if  necessary,  open  their  sheathe  sufficiently  to  catch 
their  extremities,  draw  them  down  and  unite  them  by  an  oblique 
splice,  if  possible,  with  catgut  or  fine  silver  wire,  close  the  wound, 
dress  antiseptically,  and  confine  the  extremity  in  the  position  best 
calculated  to  cause  muscular  relaxation  and  quiet  during  the  healing 
proc 

Fallacy. — If  great  care  be  not  taken,  in  case  more  than  one  tendon 
be  divided,  tin,-  tendons  of   muscles  acting  diversely  will   be  united, 
with  manifest,  results. 
11 


162 


OPERATIVE   SURGERY. 


CHAPTEE  VIII. 


OPERATIONS   ON  BONES. 


The  injuries  and  diseases  to  which  bones  are  liable,  although  not 
differing  in  any  essential  particular  from  the  same  conditions  when 
occurring  to  the  soft  parts,  require  an  independent  consideration,  on 
account  of  the  dissimilarity  of  the  function  and  structure  of  the  osse- 
ous system.  Tendons,  muscles,  nerves,  and  fasciae  are  divided  and  ex- 
cised ;  so  are  bones.  The  integument  and  soft  parts  generally,  become 
the  seat  of  inflammation,  ulceration,  and  gangrene.  Bony  tissue  is  like- 
wise preyed  upon  by  the  same  morbid  processes,  named,  however,  quite 
differently  ;  ulceration  of  the  soft  parts  being  comparable  to  caries  of 
bone,  necrosis  of  bone  finds  its  synonym  in  gangrene  of  soft  parts. 
To  preserve  the  function  of  a  tissue  unimpaired  is  the  greatest  end 
that  can  be  attained  by  surgery.  To  relieve  a  patient  of  the  local 
effects  of  an  injury  or  disease  constitutes  conservative  surgery  in  its 
fullest  sense. 

The  functions  of  bones  being,  in  a  practical  sense,  to  support  the 
body,  protect  important  organs,  and  act  as  levers  for  purposes  of  pre- 
hension and  locomotion,  we  have  but  to  act  with  a  knowledge  of  these 
purposes,  and  of  the  methods  to  maintain  them,  to  give  to  the  patient 
the  full  benefit  of  our  art.' 

The  operations  upon  bone  are  denominated  gouging,  sequestrotomy, 
excision,  osteotomy,  and  osteoplasty. 


Fig.  223. — Volkmann's  scoop. 


Fig.  224.— Hebra's  Scoop. 

Gouging  is  applied  to  the  removal  of  carious  bone,  and  should  not 
be  attempted  until  the  process  has  become  chronic. 


Fig.  225.— Chisel. 

The  instruments  required  to  meet  the  exigencies  of  .a  case  are 
gouges  (Figs.  204,  205,  206,  207),  scoops  and  chisels  (Figs.  223,  224, 


OPERATIONS   OX   BONES. 


163 


and  225),  of  various  sizes  and  shapes,  together  with  a  suitable  mal- 
let (Fig.  208). 

Operation.— Having  arranged  the  patient  in  a  position  suitable 
for  the  convenience  of  the  operator,  administer  an  anaesthetic,  apply 


Fig.  226. — Marshall's  osteotrite. 

the  elastic  bandage  if  practicable,  carrying  it  lightly  over  the  site  of 
the  disease,  and  make  a  free  incision  down  upon  the  carious  bone ; 
separate  the  soft  parts  with  retractors ;  then,  with  the  drills,  gouge, 
osteotrite,  etc.,  remove  all  the  diseased  structure. 

It  is  important  to  be  able  to  determine  the  line  between  the  healthy 
and  diseased  bone ;  and  this  is  often  very  difficult.  If  the  portions 
removed,  when  washed,  present  a  whitish,  grayish,  or  blackish  appear- 
ance, and  are  porous  and  fragile,  instead  of  being  vascular,  red,  and 
tough,  then  the  operation  should  be  continued.  If  the  gouged  sur- 
faces bleed  freely  from  numerous  points,  and  have  a  normal  firmness 
and  color,  then  the  operation  should  cease. 

It  is  important  in  gouging  the  extremities  of  bones  to  use  extreme 
caution,  or  the  joint  cavity  may  be  opened  directly,  or  become  second- 
arily involved.  After  the  removal  of  the  elastic  constriction,  all 
hemorrhage  should  be  arrested,  the  wound  washed  thoroughly  with 
a  suitable  antiseptic 
solution,  goqd  drain- 
age secured,  the  soft 
parts  united,  and 
dressed      antiseptic- 

,.  i'lG.  227. — Liston's  straight  forceps. 

ally. 

Sequestrotomy. — This  operation  is  employed  to  remove  dead  bone 
en  masse,  and  is  therefore  applicable  to  necrosis.  The  additional  in- 
struments necessary  are  small  crown  trephines,  bone-cutting  forceps 
of  various  shapes  (Figs.  227,  228,  and  229),  gnawing  forceps,  small 


Figs.  228,  229. — Liston's  curved  forceps. 

saws  (Figs.  241,  and  242,  230,  231)  and  periosteal  elevators  (Figs.  232 
and  237),  etc.    There  are  two  methods  employed,  depending  on   the 

nature  of  the  cane — viz.,  direct  and  indirect. 


164 


OPERATIVE   SURGERY. 


The  Direct  Method. — Having  detected  the  situation  of  the  necrosed 
bone,  and  being  satisfied,  either  from  the  long  course  of  the  disease, 
or  by  movement  of  the  dead  portion,  that  detachment  has  occurred, 
apply  the  elastic  bandage,  using  care  not  to  force  deleterious  matters 


Fig.  230. — Lente's  saw. 

into  the  circulation,  select  a  strong  scalpel  (Fig.  234),  and  connect 
the  fistulous  openings  with  each  other,  down  to  the  bone  ;  choosing 


Fig.  231. — Langenbeck's  key-hole  saw. 

such  openings,  of  course,  as  will  cause  the  connecting  incision  to  be 
consistent  with  good  drainage,  easy  access  to  the  diseased  parts,  and 
safety  to  the  underlying  structures.     The   surfaces  of  the  incision 


I 


Fig.  232.— Sayre's 
periosteotome. 


Figs.  233,  234.— Strong  scalpels.  Fig.  235.— Retractors. 


should  now  be  separated  with  retractors  (Fig.  235),  to  fully  expose 
the  openings  in  the  involucrum.  If  the  sequestrum  can  be  drawn  out 
of  the  opening  with  suitable  forceps,  it  should  be  done  carefully  ;  oth- 
erwise the  reparative  tissue  upon  which  it  rests  will  be  injured,  and 
the  process  of  recovery  deterred.  If  it  be  too  large,  or  be  interlocked 
with  healthy  bone,  the  opening  must  be  enlarged  sufficiently  to  admit 
of  its  withdrawal  ;  or,  if  this  be  impracticable,  an  incision  through 


OPERATIONS   ON   BOXES. 


165 


the  periosteum  should  be  made,  corresponding  to  the  long  axis  of 
the  sequestrum.  The  periosteum  should  be  carefully  raised  upon 
either  side  of  the  incision  to  permit  the  application  of  a  small  crown 
trephine,  with  which  the  inyolucrum  should  be  perforated  a  sufficient 
number  of  times  to  admit  the  easy  removal  of  the  dead  portion, 
either  with  or  without  the  chiseling  away  of  the  irregular  borders. 

The  gnawing  forceps,  chisels,  the  mallet,  and  even  small  saws,  may 
be  used  in  lieu  of  or  in  conjunction  with  the  trephine. 

Should  there  be  but  one  sinus,  and  evidences  of  disease  exist  above 
and  below  it,  the  center  of  the  incision  should  correspond  to  the  sinus, 
if  the  anatomical  relations  will  admit  of  it.  It  is  necessary  to  use  great 
caution  in  making  these  incisions  in  the  vicinity  of  joints,  or  their 
synovial  pouches  will  be  opened.  After  the  removal  of  the  dead  bone, 
the  wound,  through  its  whole  extent,  should  be  thoroughly  cleansed, 
suitable  drainage  provided,  the  lips  of  the  wound  closed,  and  anti- 
septic dressing  applied  ;  or,  after  washing,  it  can  be  lightly  filled  with 
oakum  saturated  with  balsam  of  Peru,  or  carbolic  acid  and  oil,  and 
the  whole  confined  in  place  by  a,  mass  of  carbolized  oakum,  held  in 
position  by  a  roller  bandage.  In  the  latter  instance  it  should  be 
dressed  frequently  to  secure  proper  cleanliness.  If  the  antiseptic  plan 
be  employed,  the  rales  applicable  to  the  method  should  be  strictly  ob- 
served. When  the  portion  of  bone  removed  is  large,  or  the  remain- 
ing part  is  small  and  fragile,  the  limb  must  always  be  supported  by  a 
splint  ;  otherwise  it  may  bend  or  break,  -and  thereby  complicate  the 
ultimate  result. 

If  the  sequestrum  be  as  yet  unseparated  from  the  healthy  bone,  it 
should  be  allowed  to  remain  until  the  process  of  separation  is  com- 
pleted, when  it  can  be  removed. 

The  indirect  method  is  preferable  when  the  bone  is  superficial  and 
its  disease  progressive,  as  in  ostitis  of  the  lower  jaw,  clavicle,  bones 
of  the  arm,  forearm,  or  tibia  ;  in  fact,  all  the  long  and  many  of  the 
fiat  bones  can  be  reproduced  by  this  method.  It  consists  in  making  a 
free  incision  down  upon  the  diseased  bone,  through  the  surrounding 
periosteum,  and  separating  the  membrane  by  means  of  the  handle  of 
a  scalpel,  spatula,  periosteal  elevator,  or  any  instrument  of  a  like 
character.  This  must  be  done  at  intervals,  and  not  extend  beyond 
the  diseased  portion  ;  the  length  of  the  intervals  will  depend  entirely 
upon  the  rapidity  of  the  morbid  process.  This  plan  is  necessarily  te- 
dious, both  in  detail  and  in  time  ;  yet  sooner  or  later  the  dead  bone 
can  be  raised  from  its  new  osseous  trough,  which  will  soon  become 
filled,  and  ofttimcs  serve  the  purposes  of  its  predecessor.  The  free 
incision  necessary  to  expose  the  dying  bone  will  provide  good  drain- 
age; nothing  is  necessary  other  than  this,  than  to  keep  the  wound 
clean  by  ordinary  means. 

Excision.  — Excision  of  bone  is  a  conservative  operation,  directed 


IQQ  OPERATIVE   SURGERY. 

to  the  extraction  of  such  portions  of  it  as  are  inconsistent  with  its 
future  usefulness  or  the  symmetry  of  the  part,  together  with  the  re- 
moval of  the  condition  directly  demanding  the  operation.  It  is  em- 
ployed in  lieu  of  the  more  radical  measure — amputation.  It  may  be 
directed  to  the  articular  extremities  or  to  the  shaft  of  a  bone  ;  and,  in 
either  instance,  it  may  be  partial  or  complete.  The  articular  extremi- 
ties or  joints  are  excised  on  account  of  injury,  disease,  or  ankylosis 
in  a  faulty  position.  In  estimating  the  prognosis  for  life,  the  sur- 
roundings of  the  patient,  his  previous  habits,  present  condition,  and 
the  existence  of  constitutional  taints,  must  be  considered ;  also  the 
nature  and  extent  of  the  cause  demanding  it.  The  prospective  useful- 
ness of  the  limb  will  depend  on  the  ability  to  leave  the  muscular  attach- 
ments intact ;  and  also  upon  the  condition  of  the  nerves  that  animate, 
and  the  blood-vessels  that  nourish  them.  If  the  patient  be  a  manual 
laborer,  or  be  one  over-sensitive  of  a  deformity,  it  is  well  then  to  con- 
sider if  additional  advantages  can  be  derived  from  artificial  limbs  and 
appliances,  when  it  may  be  deemed  the  wiser  to  sacrifice  the  offend- 
ing member  for  the  relief  afforded  by  amputation.  The  incisions  pre- 
paratory to  the  necessary  exposure  of  the  parts  to  be  removed  should 
be  free,  and,  when  possible,  be  made  in  the  long  axis  of  the  bone. 
They  are  often,  however,  varied,  to  suit  the  peculiar  demands  of  the 
individual  cases.  They  are  likewise  varied  for  the  different  joints, 
being  in  one  instance  longitudinal,  in  another  U,  H,  or  ==  shaped, 
according  to  the  proposed  extent  of  the  operation  and  the  contiguous 
anatomy  of  the  part.  In  every  instance,  however,  they  should  be 
made  with  a  view  to  good  drainage,  when  the  same  incision  will  ren- 
der the  parts  accessible,  and  not  expose  adjacent  important  struct- 
ures to  unwarranted  danger.  Future  usefulness  being  one  of  the 
most  important  factors  to  be  gained,  the  insertion  of  all  muscles, 
having  especially  defined  functions,  as  flexion  or  extension,  must,  if 
possible,  be  carefully  avoided.  If  it  be  necessary  to  divide  tendons,  they 
should  be  incised  obliquely,  the  better  to  facilitate  subsequent  union. 
Should  it  be  necessary  to  remove  the  bony  surfaces,  into  which  they 
or  the  ligaments  are  inserted,  the  periosteum  covering  these  surfaces 
should  be  carefully  peeled  off,  together  with  all  tendinous  attach- 
ments. All  diseased  and  loose  pieces  of  bone  should  be  removed,  to- 
gether with  irregularities  and  isolated  portions  of  articular  cartilages. 
The  synovial  membrane  should  be  preserved,  unless  it  be  diseased,  and 
its  diseased  portions  cut  or  scraped  off.  The  removal  of  the  entire 
shaft  of  a  bone  may  be  necessary  on  account  of  injury  or  disease, 
notably  the  latter.  In  such  cases  the  incision  should  be  free,  and 
made  over  its  most  superficial  aspect,  provided  that  important  struct- 
ures do  not  intervene  ;  the  periosteum  is  then  elevated  proportion- 
ately to  the  extent  of  the  disease,  gradually  or  rapidly,  as  the  circum- 
stances indicate,  and  the  diseased  bone  removed,  leaving,  if  possible, 


OPERATIONS   OX   BOXES.  107 

the  epiphyseal  extremities.  If  the  epiphyseal  cartilage  be  destroyed, 
the  growth  of  the  bone  in  its  long  axis  will  be  interrupted.  This  is 
very  important  to  observe  in  operations  upon  the  bones  of  adolescents, 
since  to  destroy  this  cartilage  will  cause  a  subsequent  shortening  of 
the  limb.  The  consultation  of  any  standard  work  on  anatomy  will 
enable  the  surgeon  not  only  to  accurately  locate  the  epiphyseal  junc- 
tions, but  likewise  inform  him  of  the  age  at  which  the  shafts  become 
united  to  their  epiphyses. 

The  time  of  operating  must  be  governed  by  the  condition  of  the 
patient,  and  also  by  the  part  to  be  operated  upon.     If  the  patient  be 

suffering  from  shock, 
reaction  should  take 
place  prior  to  oper- 
Fig.  236.— Retractor.  ative      interference. 

Should  inflamma- 
tion of  the  bone  have  occurred,  good  drainage  should  be  established, 
and  the  operation  deferred  until  the  acute  symptoms  subside.  If  the 
operation  be  for  necrosis,  the  diseased  bone  should  be  allowed  to  sepa- 
rate before  the  attempt  is  made. 

The  instruments  required  for  excision  are  varied  in  number  and 
shape,  and  must  be  selected  according  to  the  peculiarity  of  the  case. 
The  knives  should 
be  broad  and  strong 


(Figs.     233,     234).       ^^^-^"^^^^^^^^^^^^0^^ 

The  retractors  (Fig.  FlG  237._gands.  periosteotome. 

235)   must  likewise 

be  strong,  and  possess  a  hook-like  curve,  otherwise  they  will  slip  from 
the  wound.  A  sharp-hooked  retractor  may  be  employed  (Fig.  236). 
The  periosteotomes,  or  elevators  (Figs.  237,  232),  vary  in  shape,  but 
should  possess  a  blunt,  non-cutting  edge  ;  and  if  compactness  be  de- 
sired, the  elevator  may  be  connected  with  the  handle  of  the  knife 
(Fig.  234).  However,  it  is  not  so  handy  or  efficient  as  the  independ- 
ent instrument.  These  instruments  must  be  used  with  care,  other- 
wise the  function  of  the  periosteum  will  be  destroyed,  and  may  even 
be  followed  by  sloughing.  The  bone-cutting  instruments  are  forceps, 
and  saws  of  various  sizes  and  shapes.  The  straight  bone  forceps  are 
the  most  available  for  general  purposes.  The  blades  should  fit  accu- 
rately, and  be  sufficiently  sharp  to  make  as  clean  a  cut  as  possible. 
In  order  that  bone  intricately  located  may  be  reached,  the  blades  are 
brut  ai  various  angles  (Figs.  227,  228,  229).  The  gnawing  forceps  or 
rongeur  are  of  inestimable  value  in  removing  bony  projections. 

Bone-holding  Forceps  (Fig.  238)  vary  somewhal  in  their  grasping 
and  holding  power-:  consequently  the  surgeon  will  be  governed  in 
his  selection  of  an  instrument  by  it-  suitability  foT  (lie  purpose.  The 
varieties  of  saws  arc  numerous,  among  which  are  the  chain-saw  (Fig. 


168 


OPERATIVE   SURGERY. 


239),  the  straight  saw,  with  an  adjustable  back  (Fig.  241),  and  the 
curved,  for  right  and  left  sawing.     These  are  of  use  in  removing  por- 


Langenbeck's.  Ferguson's.  Faraboeuf's. 

Fig.  238. — Bone-holding  forceps. 

tions  of  thin  bones  from  flat  surfaces.     The  chain-saw,  as  the  name 
indicates,  is  composed  of  numerous  links  or  sections,  having  a  handle 


Fig.  239. — Chain-saw. 


for  working  it  attached  to  each  extremity.     To  apply  the  saw,  remove 
the  handle  from  the  hook  and  carry  it  beneath  the  bone,  with  the  cut- 


Fig.  240. — Chain-saw  carrier. 


OPERATIONS   ON   BONES. 


169 


ting  edge  upward,  by  means  of  a  thread  and  curved  needle,  or  an  in- 
strument known  as  the  "  chain-saw  carrier  "  (Fig.  240)  may  be  employed 


Fig.  241. — Lifting-back  metacarpal  saw. 

instead  ;  readjust  the  handle,  and  draw  it  from  side  to  side  at  an  angle 
of  about  45°  with  the  bone.  It  should  not  be  jerked,  or  be  allowed 
to  kink,  but  should  be  kept  taut  while  be- 
ing used,  for  fear  of  clamping  or  breaking 
it.  This  instrument  is  employed  in  divid- 
ing those  bones  which  are  nearly  surrounded 
by  the  soft  parts.  Fig.  242  represents  a  saw 
of  great  practical  worth.  The  blade  is  ad- 
justable, and  its  cutting  surface  can  be 
turned  in  any  direction  ;  it  has  therefore  a 
universal  application,  which  renders  it  su- 
perior to  the  chain-saw,  except  in  isolated 
cases.  The  gouges,  chisels,  and  mallet  are 
required  to  thoroughly  remove  all  diseased 
bone.  They  vary  in  size  and  shape,  in 
order  that  the  intricacies  of  the  wound  may 
be  reached.  The  instruments  to  seize  the 
fragments  of  bone  are  also  variously  shaped, 
to  be  better  able  to  grasp  them. 

The  Surgical  Engine. — This  is  the  out- 
come of  the  dental  engine,  the  former  being 
the  stronger  and  associated  with  suitably 
constructed  knives,  trocars,  burrs,  and  saws. 
These  instruments  are  connected  by  a  hand- 
piece which  is  attached  to  a  flexible  wire 
cable  that  permits  the  easy  holding  and  di- 
recting of  their  rapidly  revolving  surfaces. 
The  rapidity  of  their  action — two  to  three 
thousand  revolutions  per  minute — lessens 
the  pain  and  the  injury  done  to  important 
parts.  The  engine  can  be  used  with  advan- 
tage in  bone  surgery.  It  is  expensive  and 
somewhat  cumbersome,  and  therefore  bet- 
ter fitted  for  hospital  use  than  for  general 
practice. 

The  treatment  of  excision  wounds  is  in  nearly  all  instances  sub- 
stantially the  same.  Real  and  thorough  drainage,  together  with  Btrict 
antiseptic  measures,  constitute   the   basis  of  the  future   treatment. 


I'i(i.  'Jl'i. — Szymanowski'a  saw. 


170  OPERATIVE   SURGERY. 

Eest  can  be  secured  by  the  various  forms  of  splints,  either  movable 
or  immovable  in  character.  The  older  dressings  of  these  wounds  con- 
sisted of  oakum,  lint,  marine  lint,  or  a  fine  silken  oakum,  either  with 
or  without  saturation  with  carbolic  acid  and  oil,  or  balsam  of  Peru. 
If  treated  by  this  method,  they  should  be  dressed  with  sufficient  fre- 
quency to  prevent  any  septic  infection,  once  daily  being  usually 
enough.  If  the  antiseptic  methods  be  adopted,  the  rules  governing 
the  readjustment  of  the  dressings  should  be  enforced. 

Excision  of  the  Upper  Jaw. — This  operation  is  done  for  various 
diseases,  connected  either  with  the  bone  structure  itself  or  the  cavi- 
ties with  which  it  is  associated.  In  all  instances  the  periosteum  should 
be  preserved,  except  those  in  which  it  is  invaded  by  malignant  disease. 

The  special  instruments  requisite — in  addition  to  those  already 
enumerated  for  excisions — are  a  trephine,  or  a  bone-drill  and  a  strong 
pair  of  forceps  to  turn  or  twist  the  bone  out  of  its  cavity,  together 
with  forceps  to  draw  the  teeth  in  the  line  of  section.  The  patient 
is  anesthetized  and  placed  upon  the  back,  either  with  the  head  slight- 
ly raised  or  markedly  depressed.  In  the  latter  position  the  blood 
does  not  escape  into  the  larynx,  but  into  the  upper  and  posterior 
part  of  the  pharynx.  This  position,  however,  impedes  respiration 
by  undue  stretching  of  the  tissues  of  the  anterior  cervical  region. 
However,  this  may  be  obviated,  in  a  great  degree,  if  the  foot  of  the 
table  be  raised,  as  for  the  reduction  of  the  abdominal  contents  by 
taxis.  If  the  head  be  elevated,  the  blood  can,  with  care,  be  kept  from 
the  larynx,  either  by  constant  sponging  or  tamponing  the  pharynx 
around  a  large  catheter  or  rubber  tube,  or  permitting  the  patient  to  be 
sufficiently  conscious  to  dislodge  it.  Still  another  method  is  to  confine 
the  patient  in  a  rocking-chair,  which  can  be  tipped  forward  or  back- 
ward as  circumstances  require.  The  surest  of  all  is  to  perform  a  pre- 
liminary tracheotomy,  and  then  tampon  the  floor  of  the  pharynx. 
This  is  not  as  a  rule  necessary  unless  the  operation  be  complicated 
with  a  very  vascular  morbid  process  requiring  a  separate  removal. 
If  the  important  associated  anatomy  be  carefully  considered  before 
beginning  the  operation,  it  will  save  much  time  and  not  a  little  blood. 

In  complete  removal,  the  bony  connections  which  must  be  divided 
are  :  1.  With  the  malar,  below  the  outer  angle  of  the  orbit.  2.  With 
the  fellow  of  the  opposite  side  in  the  roof  of  the  mouth.  3.  The  nasal 
process  of  the  bone,  with  its  body  below  the  inner  angle  of  the  orbit. 
4.  The  slight  connection  between  it  and  the  palate  bone  and  pterygoid 
processes  of  the  sphenoid.  The  internal  maxillary  artery  in  the  spheno- 
maxillary fossa  and  the  branches  of  the  facial  artery  running  through 
the  external  soft  parts  are  the  only  vessels  that  will  cause  troublesome 
hemorrhage.  Steno's  duct  must  be  avoided,  as  it  runs  from  the  pa- 
rotid gland  to  empty  into  the  mouth  opposite  the  second  molar  tooth, 
on  a  line  extending  from  the  lobule  of  the  ear  to  midway  between  the 


OPERATIONS   ON   BONES. 


171 


border  of  the  lip  and  the  ala  of  the  nose.    The  superior  branches  of  the 
seventh  pair  of  cranial  nerves  may  be  divided  unnecessarily  if  the  course 


Fig.  243. — Linear  guides  for  removal  of  upper  jaw. 

or  extent  of  the  incisions  be  too  great.  All  anticipated  complications 
should  be  carefully  studied,  and  provisions  made  for  their  treatment. 
Loss  of  blood,  however,  is  the  only  one  in  addition  to  the  shock  com- 
mon to  all  operations  that  requires  close  attention.  Hemorrhage  from 
the  facial  and  internal  maxillary  arteries,  while  often  profuse,  can  be 
easily  controlled. 

The  Lines  of  Incision.—  They  may  be  made  within  or  without  the 

buccal  cavity. 

To  attempt  the  removal  from  within  is  too  tedious,  the  space  being 
limited  and  the  ability  to  control  hemorrhage  entirely  inadequate. 
At  the  present  time  external  incisions  only  are  practical.  These  can 
be  classed  as  the  outer,  and  the  median.  The  former  (Lizar's)  com- 
mencing at  the  angle  of  the  mouth  and  passing  in  a  curved  course 
upward  and  outward  to  the  malar  process  (Fig.  243,  a)  ;  if  more  room 
be  needed  it  may  be  supplemented  by  an  incision  through  the  upper 
lip  to  the  nostril,  also  by  extending  the  first.  This  incision  exposes 
St.  no's  duct  and  the  branches  of  the  seventh  nerve  to  injury,  and  is 
followed  by  a  conspicuous  scar. 

Listen  made  an  incision  from  below  the  external  angular  process 
of  the  frontal  bone  to  the  angle  of  the  mouth  ;  if  necessary,  a  sec- 
ond «ras  also  made  along  the  zygoma  joining  the  first  (Fig.  21:5.  <■), 
and  even  a  third  from  the  nasal  process  of  the  maxilla  downward  to 


172 


OPERATIVE   SUKGERY. 


the  lip  in  the  median  line.  Velpeau,  like  Lizar,  made  a  single  curved 
incision  with  the  convexity  downward  from  the  angle  of  the  mouth 
to  the  malar  hone,  and  even  to  the  angle  of  the  orbit  if  necessary. 
The  last  (Ferguson's),  and  an  admirable  one,  is  made  at  the  middle 
of  the  upper  lip,  and,  following  the  furrows  between  the  cheek  and 
nose,  terminates  about  half  an  inch  below  the  inner  angle  of  the 
eye  (Fig.  243,  b).  To  this  may  be  added  an  incision  of  an  inch  or  so 
in  length,  extending  outward  half  an  inch  below  the  orbit,  and  at  a 
right  angle  with  the  vertical  one,  or  it  may  be  extended  to  the  external 
angle  of  the  orbit  and  the  zygoma  if  necessary.  In  this  incision  the 
coronary  and  angular  arteries  only  are  divided. 

Operation  ly  the  Median  Incision,  with  Removal  of  the  Whole 
Bone. — The  middle  incisor  tooth  corresponding  to  the  side  to  be  oper- 
ated upon  is  drawn,  and  the  facial  artery  compressed  on  both  sides  by 
an  assistant.  The  incision  is  begun  at  the  border  of  the  lip,  and  in  or- 
der to  prevent  blood  from  entering  the  mouth,  it  is  not  carried  through 
it  until  later,  from  the  upper  attachment  of  the  lip,  through  the  re- 
mainder of  the  course,  the  incision  is  rapidly  made  down  to  the  bone,  and 
the  flap  dissected  outward  as  far  as  the  malar  bone  above,  and  the  tuber- 
osity of  the  maxilla  below ;  during  the  dissection  the  bleeding  points 
are  controlled  by  the  fingers  of  the  assistant  or  by  the  serrefine  forceps. 
All  vessels  should  be  ligated  with  catgut  before  the  bone  is  removed. 
The  cartilage  of  the  nose  is  separated  from  the  bone  and  turned  inward, 
the  edge  of  the  orbit  gained,  and  the  periosteum  on  the  floor  separated 

and  pushed  backward 
and  upward  by  means 
of  an  elevator  or  han- 
dle of  a  scalpel  to  the 
border  of  the  spheno- 
maxillary fissure.  The 
malar  process  is  now 
divided  by  sawing,  or 
cutting  through  i  t 
with  bone  -  forceps, 
from  the  outer  extrem- 
ity of  the  spheno-max- 
illary  fissure.  The  thin 
floor  of  the  orbit  is 
divided  with  a  scalpel 
from  the  spheno-max- 
illary  fissure  obliquely 
forward  and  inward, 
and  the  nasal  process  severed  with  forceps  (Fig.  244).  The  mucous 
membrane  of  the  roof  of  the  mouth  is  then  divided  transversely  in- 
ward to  the  center,  on  a  line  with  the  last  molar  tooth,  then  from  the 


Fig.  244. — Division  of  processes  of  superior  maxilla. 


OPERATIONS   ON   BONES. 


173 


center  forward,  in  the  median  line,  to  the  incisor  teeth.  The  hard 
palate  is  divided  at  the  side  of  the  septum,  corresponding  to  the  bone 
to  be  removed,  by  a  saw  or  bone-forceps,  and  the  bone  seized  and  pressed 
downward  to  break  up  its  posterior  connections,  after  which  it  is  raised 
and  twisted  slightly  from  side  to  side  and  pulled  out,  bringing  with  it 
some  portions  of  the  palate  bone  and  pterygoid  process  of  the  sphenoid, 
together  with  the  muscular  fibers  connected  with  them.  If  the  mucous 
membrane  of  the  mouth  be  not  diseased,  it  can  be  saved  by  making  an 
incision  through  it  along  the  alveolar  border,  and  pushing  it  inward 
together  with  the  periosteum  to  the  median  line.  After  the  removal 
of  the  bone  the  periosteum  can  be  stitched  to  the  side  of  the  cheek. 

Excision  Beloiv  the  Floor  of  the  Orbit. — After  the  exposure  of  the 
external  surface  of  the  superior  maxilla,  as  in  the  preceding  method, 
perforate  the  anterior  wall  of  the  antrum  with  a  drill  or  trephine  ; 
then,  with  the  bone  forceps  or  saw  inserted  into  the  opening,  divide 
the  bone  through  into  the  nasal  fossa,  and  separate  it  from  its  outer 
connections  by  sawing  or  cutting  through  the  malar  bone.  Aside  from 
this  the  steps  of  both  are  similar. 

After  the  operation  the  wound  is  washed  with  carbolic  acid,  and 
all  bleeding  points  checked  either  by  ligature,  pressure,  or  cautery, 
the  first  being  the  best.  The  external  incision  is  then  closed  with 
sutures  or  pins,  and  readily  unites  in  three  or  four  days.  The  raw 
surfaces  within  should  be  kept  thoroughly  cleansed  while  repair  is 
taking  place.  These  cases  make  a  satisfactory  recovery  from  the  opera- 
tion, although  some  deformity  always  remains. 

The  stitches  are 
removed  from  the 
soft  parts  the  third 
or  fourth  day,  un- 
ion, as  a  rule,  being 
complete. 

The  results  of 
this  operation  are 
good,  so  far  as  im- 
mediate loss  of  life 
is  concerned.  About 
one  in  five  or  six 
die.  If  the  removal 
be  done  for  malig- 
nant growths,  the 
prognosis  for  ulti- 
mate recovery  is  an-  / 
favorable. 

S  a  h  /i  <■  r  iosteal 
l."i$ion. — Tli  is  can  be  done  with  any  of  the  median  incisions,  but  an 


Fig.  245. — Subperiosteal  excision  of  upper  jaw. 


174 


OPERATIVE   SURGERY. 


external  one  is  preferred  by  some  (Fig.  245).  The  external  incision  is 
made  from  the  middle  of  the  malar  bone  to  a  point  on  the  upper  lip, 
one  third  of  an  inch  from  the  angle  of  the  mouth  (Oilier).  It  is  some- 
times necessary  to  make  a  second  incision  from  the  middle  of  the  lip 
upward  to  the  nose  (dotted  line,  Fig.  245),  as  in  the  preceding  oper- 
ation. The  mucous  membrane  on  the  external  surface  of  the  alveolar 
process  is  divided  down  to  the  bone  ;  beginning  at  the  line  of  junction 
between  the  lateral  incisor  and  canine  teeth  and  carried  backward  to 
and  around  the  posterior  molar  to  the  inner  surface  of  the  alveolar 
process,  forward  parallel  with  the  external  incision  to  a  point  opposite 
the  commencement  of  the  external  incision,  then  obliquely  backward 
and  inward  on  a  line  corresponding  to  the  intermaxillary  suture  of  that 
side,  to  the  median  line.  The  anterior  extremities  of  the  external  and 
internal  incisions  are  now  connected  with  each  other  by  a  transverse 
incision,  carried  on  a  line  extending  between  the  lateral  incisor  and  ca- 
nine teeth.  The  periosteum  is  then  peeled  off  from  the  external  and 
orbital  surfaces  of  the  bone,  and  also  from  the  inner  surfaces  of  the  al- 
veolar process,  and  the  hard  palate  of  that  side.  The  nasal  and  malar 
processes  are  divided  as  before,  the  canine  tooth  drawn,  and  the  inter- 
maxillary bone  separated,  together  with  the  hard  palate  of  the  maxilla 
to  be  removed,  from  the  contiguous  bone,  by  the  chisel,  saw,  or  for- 
ceps. The  maxilla  is  then  twisted  out,  and  the  periosteum  from  the 
inner  and  outer  surfaces  of  the  alveolar  process  united. 


Fig.  246. — Removal  of  both  superior  maxillae 


The  superior  maxillae  may  be  removed  simultaneously  by  either 
of  two  methods.     1.  Make  an  incision  from  each  angle  of  the  mouth 


OPERATIONS   OX   BOXES.  175 

to  the  middle  of  the  malar  bone  on  the  respective  sides  (Fig.  246,  a), 
and  dissect  upward  the  intervening  flaps  ;  or,  2,  make  a  vertical  one 
(Fig.  246,  b)  along  the  ridge  of  the  nose  through  the  lip,  beginning 
at  a  point  one  fourth  of  an  inch  below  the  lower  border  of  the  orbit 
(Dieffenbach).  To  this  maybe  added  a  transverse  incision  one  fourth 
of  an  inch  below,  and  extending  to  opposite  the  middle  of  each  orbit, 
across  the  upper  end  of  the  vertical  incision  (dotted  line,  Fig.  246) ; 
the  outer  bony  attachments  are  divid?d  as  in  the  single  operation  ;  the 
nasal  processes  are  divided  either  by  forceps  or  the  saw,  and  both  bones 
removed  at  once — not  separately.  In  all  operations  for  the  complete 
removal,  the  superior  maxillary  nerve  should  be  divided  as  far  back  as 
possible.  The  bones  may  be  removed  separately  in  the  manner  de- 
scribed for  the  removal  of  a  single  superior  maxilla. 

Results. — About  thirty  per  cent  die  from  whom  both  bones  are 
removed  simultaneously. 

Excision  of  the  Inferior  Maxilla. — The  operations  on  the  lower  jaw 
require  no  additional  instruments  ;  the  precautions  referable  to  the 
patient  are  almost  of  equal  importance,  and  the  contiguous  anatomy 
is  even  more  important  than  for  the  upper.  The  facial  artery  runs 
beneath  and  across  its  lower  border  and  on  its  outer  surface  at  the 
anterior  border  of  the  masseter  muscle  ;  the  parotid  gland  lies  behind 
the  ramus,  and  often  overrides  it.  The  external  carotid  artery,  as  it 
passes  through  the  gland,  is  closely  associated  with  its  posterior  bor- 
der. The  internal  maxillary  artery  runs  closely  behind  and  to  the 
inner  side  of  the  neck  of  the  condyle.  The  inferior  dental  artery  runs 
along  the  inner  surface  of  the  ramus  to  enter  its  canal.  The  superior 
division  of  the  seventh  pair  of  nerves  passes  across  the  outer  border  of 
the  neck  of  the  condyle.  Steno's  duct  passes  across  the  masseter 
muscle  to  its  opening  opposite  the  second  molar  tooth,  on  a  line  par- 
allel with  and  about  an  inch  below  the  lower  border  of  the  zygoma. 
The  lingual  nerve  runs  along  the  inner  surface  of  the  ramus,  close  to 
the  bone  just  below  the  last  molar  tooth. 

The  genio-hyo-glossus  muscle  is  attached  to  the  superior  genial 
tubercles,  and,  if  incautiously  detached,  will  permit  the  tongue  to  fall 
backward  and  close  the  glottis.  It  is  very  important,  when  possible, 
to  preserve  the  attachments  of  the  muscles  of  mastication,  on  account 
of  their  action  on  the  resultant  tissues.  The  operation  may  be  directed 
to  a  complete  or  partial  removal  of  the  bone.  A  partial  removal  may 
include  any  fractional  portion  of  it. 

TJie  incisions  for  the  removal  maybe  made  within  the  mouth  or 
on  the  external  surface.  If  the  whole  or  a  lateral  half  is  to  be  re- 
moved, an  external  incision  must  be  made.  The  portion  in  front  of 
the  molar  teeth,  and  even  in  front  of  the  ramus,  can  he  excised  l>\  in- 
ternal incisions  alone  ;  the  latter  is,  however,  often  attended  by  vex- 
ations difficulties,  and  is  hardly  warrantable,  except  in  selected  eases. 


176  OPERATIVE   SURGERY. 

The  ramus  and  portions  of  the  body  behind  the  teeth  can  be  removed 
through  an  external  incision  without  opening  into  the  buccal  cavity, 
provided  the  periosteum  be  carefully  raised  from  its  surface.  In  the 
same  manner  the  body,  or  any  portion  of  it,  may  be  taken  away  if  the 
teeth  be  absent.  If  the  teeth  be  present,  the  periosteum  may  be  care- 
fully detached,  and  the  bone  with  the  teeth  removed,  after  which  the 
openings  of  the  buccal  cavity,  caused  by  the  withdrawal  of  the  teeth, 
can  be  closed  by  sutures  applied  internally.  If  the  jaw  be  the  seat  of 
phosphoric  or  other  necrosis,  it  may  be  gradually  enucleated,  through 
an  external  opening,  from  its  surrounding  involucrum,  by  the  indi- 
rect method,  and  the  teeth  may  even  remain  in  the  new  growth.  Un- 
fortunately, however,  when  processes  of  a  malignant  nature  call  for 
the  operation,  these  conservative  methods  are  of  no  avail,  since  the 
operation  must  be  directed  to  the  removal  of  all  the  diseased  tissues. 
When  possible,  the  incision  in  the  buccal  lining  should  be  closed,  and 
the  wound  drained  externally.  This  will  keep  the  mouth  clean,  and 
prevent  swallowing  the  discharges. 

Excision  of  the  Central  Portion. — Pass  a  stout  ligature  through 
the  tongue  well  behind  its  tip,  to  prevent  tearing  out,  and  tie  the  ends 
to  form  a  loop,  which  will  be  convenient  for  keeping  it  from  falling 
backward.  The  assistant  stands  behind  the  head  of  the  patient,  holds 
the  loop  firmly,  at  the  same  time  compressing  the  facial  arteries  where 
they  pass  across  the  jaw  ;  or  seizes  the  lower  lip  at  the  angles  between 
the  thumbs  and  fingers,  rendering  it  tense,  and  at  the  same  time  arrest- 
ing its  circulation.  The  operator,  standing  in  front,  makes  a  vertical 
incision  through  the  median  line  down  to  the  bone,  extending  to  the 
lower  border  of  the  symphysis  mentis,  raises  the  periosteum  from  its 
surfaces,  if  practicable,  to  the  extent  of  the  proposed  section,  draws  a 
tooth  at  each  point  where  the  bone  is  to  be  divided,  saws  it  at  these 
points,  and  draws  the  fragment  forward  and  separates  the  attachments 
of  the  muscles  as  closely  as  possible  to  their  insertion.  The  flaps  are 
then  united  with  silver  wire,  extending  through  the  mucous  membrane. 
The  vermilion  border  of  the  lip  is  carefully  adjusted,  and  united  with 
pins  or  silver  sutures.  If  the  tongue  fall  backward,  its  severed  mus- 
cular attachments  can  be  drawn  forward,  and  connected  with  the  in- 
cision in  the  median  line  by  a  deep  suture  passed  through  the  lip. 
The  bone  can  be  easily  reached  through  a  curved  incision  made  along 
its  lower  border,  or  by  an  internal  one  corresponding  to  the  fold  of  the 
buccal  membrane.  The  lip  is  depressed  over  the  symphysis  mentis, 
and  the  bone  is  removed. 

Excision  of  the  Lateral  Portion  of  the  Body. — Make  an  external 
incision  along  the  under  border  of  the  portion  to  be  removed,  down  to 
the  bone.  If  necessary,  the  incision  may  be  turned  upward  at  a  right 
angle  toward  but  not  through  the  lip.  If  the  condition  of  the  parts 
will  permit,  the  periosteum  is  reflected  off,  the  bone  divided  in  front, 


OPERATIONS   ON   BONES. 


177 


external  to  insertion  of  the  genio-hyo-glossus  muscle,  and  if  possible 
turned  outward,  and  the  tissues  separated  back  to  the  point  of  posterior 
section  ;  it  is  then  removed  with  a 
chain-saw,  and  dressed  as  before. 
Excision  of  Half  of  the  Lower 
Jaw. — Commence  the  incision 
about  an  inch  and  a  half  below 
the  arch  of  the  zygoma,  and  carry 
it  downward  along  the  posterior 
border  of  the  ramus,  and  beneath 
the  body  of  the  jaw  to  the  sym- 
physis mentis,  carefully  exposing 
the  facial  artery  and  tying  it. 
If  the  operation  be  for  necrosis, 
this  incision  will  be  sufficient ; 
if  for  other  disease,  the  lower  lip 
is  cut  perpendicularly  through 
its  center  to  meet  the  longitudi- 
nal incision  (Fig.  247).  The 
bone  is  exposed  in  front  by  peel- 
ing off  the  periosteum  or  other- 
wise, and  sawn  through  just  to 
the  outer  side  of  the  insertion  of 
the  genio-hyo-glossus  muscle  if 
possible,  the  end  pulled  outward,  and  the  remaining  attached  tissues 
separated  either  by  cutting  or  by  a  periosteotome,  back  to  the  begin- 
ning of  the  incision.     Depress  the  fragment  forcibly,  and  if  possible 

detach  the  temporal 
muscle  with  scissors 
or  the  periosteotome, 
then  turn  the  bone 
outward,  and  divide 
the  insertions  of  the 
pterygoid  muscles  in 
the  same  manner,  care- 
fully avoiding  cutting 
the  lingual  nerve,  draw 
the  bone  forward  for- 
cibly and  twist  it  from 
its  socket  (Fig.  248). 

If  it  be  impossible! 
to   accomplish  its   re- 
moval in  this  manner, 
extend  the  incision  up- 
].-,,;.  24ft, — Severing  cona  ctioni  "l  Inferior  maxilla.  wan!  CO  the  QetiK  "I  the 

12 


Fib.  247. — Linear  guide  for  removal  of  lialf 
the  lower  jaw. 


178  OPERATIVE   SURGERY. 

bone  (dotted  line,  Fig.  247),  avoiding  if  possible  the  division  of  Steno's 
duct  and  the  cervico-facial  branch  of  the  seventh  pair  of  nerves,  and 
enucleate  the  condyle.  In  this  situation  the  condyle  must  be  closely 
followed,  otherwise  the  internal  maxillary  artery  may  be  injured,  as  it 
passes  immediately  behind  it.  If  the  primary  incision  be  sufficient  to 
expose  the  bone  above  the  seat  of  the  disease,  it  should  be  sawn  through 
at  this  point  and  the  upper  portion  allowed  to  remain. 

Excision  of  the  Entire  Loiver  Jaw. — Remove  the  left  half  first,  or 
the  right  if  it  best  suits  the  convenience  of  the  operator,  in  the  manner 
before  described.  A  ligature  is  then  passed  through  the  tongue,  given 
to  an  assistant,  and  the  remaining  half  of  the  bone  excised  in  a  similar 
manner.  Arrest  all  hemorrhage,  and  close  the  wounds  with  sutures 
in  such  a  way  as  to  accurately  coaptate  the  divided  buccal  borders. 

In  all  situations,  when  the  nature  of  the  disease  will  permit,  the 
periosteum  should  be  reflected  by  a  careful  yet  vigorous  use  of  the 
elevator.  The  insertions  of  ligaments  and  tendons  will  offer  the  only 
obstacle,  and  these  should  be  carefully  detached  by  a  sharp  knife,  that 
a  continuity  of  the  periosteal  and  fibrous  tissues  may  remain. 

The  periosteum  in  young  subjects  may  reproduce  enough  bony 
material  to  give  a  fair  outline  to  the  face  and  serve  an  important  func- 
tion in  mastication. 

If  bone  be  not  reproduced,  the  periosteum  will  furnish  a  firm 
fibrous  base,  which  may  be  utilized  for  artificial  appliances.  If  the 
anterior  portion  of  either  or  both  sides  be  removed,  the  gap  may  be 
filled  in  by  an  artificial  dental  appliance,  which  will  often  happily 
maintain  the  symmetry  of  the  face  and  become  useful  in  mastication. 

Excision  of  the  Alveolar  Process. — When  the  extent  of  the  disease 
will  permit,  the  alveolar  process  can  be  removed  down  to  the  body  of 
the  jaw  through  either  an  external  or  internal  incision,  the  former  be- 
ing the  better.  The  diseased  part  is  then  removed,  and  the  wound  closed 
as  before.  After  recovery,  the  body  of  the  jaw  will  form  an  excellent 
foundation  for  a  compensatory  dental  appliance.  Whenever  the  disease 
is  malignant,  the  periosteum  should  be  removed  with  the  bone,  and  care 
taken  that  none  of  the  diseased  membrane  remains  in  the  wound.  It  is 
also  necessary  in  such  cases  to  remove  all  associated  structures  when 
diseased — such  as  glands,  floor  of  the  mouth,  and  even  the  tongue  itself. 

Results. — Out  of  two  hundred  and  forty-six  excisions  in  the  con- 
tinuity, forty-six  died.  Of  one  hundred  and  fifty-three  disarticula- 
tions of  one  half  the  bone,  thirty-six  died.  In  twenty  operations  for 
removal  of  the  entire  jaw,  one  died.  It  will  be  seen  that  death  has 
followed  in  twenty  per  cent,  of  all  the  cases.  Pyeemia,  erysipelas,  and 
exhaustion  were  the  principal  causes. 

Operation  for  Anchylosis  of  the  Inferior  Maxilla.— This  consists  in 
establishing  a  false  joint  in  front  of  the  cause  of  the  immobility,  which 
is  usually  dependent  on  cicatricial  contraction,  irreducible  dislocation, 


OPERATIONS   ON   BONES.  179 

or  anchylosis.  The  removal  of  a  wedge-shaped  piece  from  the  lower 
border  of  the  jaw,  or  from  the  alveolar  process,  has  been  practiced  ; 
or  a  transverse  section  of  the  ramus  with  a  sharp  chisel  introduced 
through  the  mouth,  or  even  fracture  of  the  neck  when  the  condyle  is 
involved,  has  relieved  the  condition. 

Operation  for  Removal  of  a  Wedge-shaped  Piece  (Esmarch). — 
Make  an  incision  two  inches  in  length  down  to  the  bone,  along  the 
lower  border  of  the  jaw,  beginning  at  or  in  front  of  its  angle,  depend- 
ing upon  the  location  of  the  cause  of  the  immobility.  Avoid  or  tie  all 
important  vessels  in  the  course  of  the  incision  ;  expose  both  surfaces 
of  the  bone  up  to  the  summit  of  the  alveolar  process,  and  pull  a  tooth 
if  necessary.  Divide  the  bone  with  a  chain-saw  at  one  extremity  of 
the  exposed  surface,  force  the  other  extremity  through  the  wound,  and 
remove  the  wedge-shaped  piece  with  the  rongeur  or  saw,  the  base  of 
which  should  not  exceed  a  third  or  half  an  inch.  While  the  patient 
is  still  under  the  influence  of  the  anaesthetic  and  before  the  wound  is 
closed,  ascertain  the  distance  the  liberated  portion  can  be  separated 
from  the  upper  jaw  with  moderate  force.  Provide  suitable  drainage, 
close  the  wound,  and  prevent  union  of  the  bones  by  passive  motion. 

Rizzoli,  of  Bologna,  recommends  a  simple  section  of  the  bone  in- 
stead of  the  removal  of  a  wedge-shaped  piece  ;  however,  the  results  of 
this  method  do  not  warrant  its  substitution  for  the  former.  If  the 
cause  of  the  immobility  be  due  to  anchylosis  of  the  temporo-m axillary 
articulation,  the  condyle  should  be  removed,  or  the  ramus  be  so  di- 
vided as  not  seriously  to  impair  the  functions  of  the  masseter  muscle, 
that  is,  divided  beneath  that  muscle.  The  division  of  the  neck  of  the 
bone  by  a  straight  chisel  introduced  through  the  mouth  (Grube)  has 
been  practiced.  After  either  operation  it  may  be  necessary  to  divide  the 
masseter  muscle  before  the  full  benefit  can  be  experienced  from  the  di- 
vision or  the  removal  of  the  bone.  If  it  be  determined  to  remove  the 
condyle,  a  curvilinear  incision,  corresponding  to  the  location  of  the  por- 
tion of  bone  to  be  removed,  is  made  down  to  it,  when,  by  means  of  a 
chisel,  saw,  or  forceps,  the  neck  of  the  bone  is  divided  at  the  proper 
place,  the  fragment  turned  outward  by  forceps,  its  attachments  divided, 
and  the  bone  removed.   Passive  motion  should  follow  the  same  as  before. 

Excision  of  the  Sternum. — No  definite  plan  for  this  operation  can 
be  outlined.  The  form  and  length  of  the  incisions  must  be  governed 
by  the  location  and  extent  of  the  disease.  The  diseased  bone  should 
be  freely  exposed,  and  removed  in  the  usual  manner.  Care  must  bo 
observed,  else  the  pleural  cavity  will  be  opened.  When  possible,  sub- 
periosteal excision  should  be  done,  as  the  bono  is  qnite  readily  repro- 
duced. The  entire  sternum  is  reported  to  have  been  removed  by 
Koni^  on  account  of  a  sarcomatous  tumor  involving  its  structure,  and, 
even  though  the  pericardium  and  pleural  cavity  were  opened,  the  pa- 
tient ultimately  recovered. 


180  OPERATIVE   SURGERY. 

Results.—  Partial  excision,  cautiously  done,  results  most  favorably  ; 
only  one  in  eighteen  died. 

Excision  of  a  Portion  of  a  Rib. — This  may  be  done  for  the  removal 
of  necrosed  bone,  or  to  make  a  permanent  opening  into  the  thorax  for 
the  escape  of  pus.  If  for  diseased  bone,  make  an  incision  in  the  mid- 
dle of  the  long  axis  of  the  rib  of  sufficient  length  to  include  the  dis- 
eased portion.  This  may  be  crossed  at  the  middle  by  a  transverse 
incision.  Separate  the  periosteum  along  with  the  superimposed  tis- 
sues, liberate  the  bone,  and  raise  it  from  its  bed.  If  the  sequestrum 
be  not  loose,  time  should  be  allowed  for  its  separation.  If  the  opera- 
tion be  for  pyo-thorax,  select  the  sixth  or  seventh  rib  ;  make  an  incis- 
ion in  a  line  with  the  axilla  about  two  or  three  inches  in  length  down 
upon  the  middle  of  the  rib,  through  the  periosteum  ;  bisect  this  by  a 
horizontal  one  of  the  width  of  the  rib,  expose  the  bone  on  both  sur- 
faces by  raising  the  periosteum  together  with  its  surrounding  tissues, 
being  careful  as  yet  not  to  open  into  the  pleural  cavity ;  exsect  one 
half  or  three  fourths  of  an  inch  of  the  bone,  dividing  it  with  a  chain- 
saw.  If  the  intercostal  artery,  which  lies  beneath  its  lower  border, 
be  cut,  tie  it ;  then  make  a  suitable  opening  through  the  intervening 
structures  into  the  pleural  cavity. 

It  is  well  to  make  the  first  incision  corresponding  to  the  long  axis 
of  the  rib,  and  thus  the  more  surely  avoid  the  intercostal  vessels  and 
nerves.     The  wound  should  be  dressed  antiseptically. 

Excision  of  the  Clavicle. — This  operation  is  performed  for  necrosis 
and  for  morbid  growths  of  the  clavicle.  The  patient  is  placed  on  the 
back,  with  the  shoulders  elevated  from  the  table  and  the  head  turned 
to  the  opposite  side. 

Contiguous  Anatomy. — The  muscular  and  ligamentous  attachments 
of  the  clavicle  must  be  carefully  studied,  for  it  is  by  a  knowledge  of 
them  that  the  surgeon  is  enabled  to  raise  the  bone  safely  from  its 
more  important  relations. 

In  front. 
Attachments  of — 
Pectoralis  major  muscle. 
Sterno-mastoid  muscle. 
Trapezium  and  deltoid  muscles. 
Above. 
External  jugular  vein. 

Branches  of  thyroid  axis.      f  i  Below. 

Subclavian  artery.  (   Clavicle,   j-  Cephalic  vein. 

Brachial  plexus. 

Behind. 
Internal  mammary  artery — sternal  half. 
Subclavian  vein,  "  " 

External  jugular  vein. 
Innominate  vein  at  the  right. 
Thoracic  duct  at  the  left. 
Pleura. 


OPERATIONS   ON   BONES.  181 

The  intimate  association  of  the  clavicle  to  important  arteries, 
veins,  nerves,  etc.,  surrounds  its  removal  with  great  difficulties  and 
dangerous  complications  ;  especially,  if  it  be  attempted  for  a  well- 
developed  malignant  or  other  morbid  growth.  With  the  patient  in 
the  proper  position  for  the  operation,  the  foregoing  plan  shows  the 
important  anatomical  relations  of  the  clavicle. 

The  whole  or  a  portion  of  the  bone  can  be  removed.  If  the  whole 
bone  is  to  be  removed,  it  may  be  raised  by  its  scapular  extremity,  or 
divided  at  its  middle,  and  each  half  taken  away  separately. 

Excision  of  the  entire  Clavicle. — Anaesthetize  and  place  the  patient 
in  the  position  above  described  ;  if  the  operation  be  for  necrosis,  make 
an  incision  the  whole  length  of  the  bone  parallel  with  its  long  axis.  If 
necessary,  a  short  transverse  incision  is  added  ;  expose  the  clavicle, 
divide  the  periosteum,  and  with  the  elevator  enucleate  the  diseased 
bone  from  the  surrounding  tissues.  The  clavicle  can  be  divided 
through  the  center  and  each  half  removed  separately,  or  the  acromial 
end  can  be  detached  and  the  entire  bone  raised  from  without  inward. 
In  either  instance,  the  articular  ends  and  their  connecting  ligaments 
should  be  preserved  if  possible. 

If  the  involucrum  be  weak  and  liable  to  bend  or  break  after  the 
bone  is  removed,  the  shoulder  must  be  held  outward,  backward,  and 
upward  by  means  of  the  method  employed  in  treatment  of  fracture  of 
that  bone.  The  indirect  method  of  sequestrotomy  can  be  performed 
in  some  instances. 

If  the  operation  be  for  the  removal  of  a  tumor  of  this  bone,  espe- 
cially of  one  acutely  malignant,  and  involving  any  considerable  portion 
of  its  surrounding  tissues,  it  is  certain  to  be  an  exceedingly  tedious 
and  bloody  procedure. 

The  smaller  the  size  of  the  tumor  and  the  less  its  vascularity,  the 
easier  will  be  its  removal. 

Operation. — Make  an  incision  in  the  long  axis  of  the  bone,  from 
its  sternal  to  its  acromial  extremity  ;  if  necessary,  this  is  crossed  by  a 
vertical  incision,  extending  from  the  posterior  border  of  the  sterno- 
mastoid  muscle  to  the  upper  third  of  the  pectoralis  major  muscle. 
Make  these  incisions  as  deep  as  the  nature  of  the  growth  will  permit, 
and  dissect  the  flaps  from  the  tumor ;  separate  the  insertions  of  the 
deltoid  and  the  trapezius  muscles  on  a  director,  cutting  them  either 
with  a  knife  or  strong  curved  scissors,  being  careful  to  avoid  the 
cephalic  vein  which  lies  at  the  inner  border  of  the  deltoid  muscle. 
Divide  the  coraco-  and  acromio-clavicular  ligaments  ;  raise  the  acro- 
mial extremity  of  the  clavicle,  and  thus  elevate  the  morbid  growth, 
which  should  then  be  cautiously  separated  from  the  surrounding  tis- 
sues. The  nearer  the  approach  to  the  Bternal  extremity  of  (be  clavi- 
cle, the  greater  will  be  the  necessity  for  caution,  since  the  growth  may 
be  connected  with  the  importanl  structures  Located  in  this  situation \ 


182 


OPERATIVE  SURGERY. 


finally,  divide  the  insertions  of  the  sterno-mastoid  and  the  pectoralis 
major  muscles,  and  rhomboid  ligament,  and  carefully  disarticulate  the 
sternal  extremity  while  the  tumor  is  lifted  upward  and  inward  to- 
gether with  the  clavicle. 

Either  extremity  of  the  clavicle  may  be  excised  by  making  a  cru- 
cial incision  down  to  the  bone  corresponding  to  the  portion  to  be 
removed,  exposing  and  dividing  it  with  a  chain-saw,  and  removing  the 
fragment  with  the  same  precautions  as  before  described. 

The  results  of  the  operation  of  complete  excision  have  been  quite 
favorable  ;  of  thirty-four  cases,  six  proved  fatal.  Exhaustion,  due  to 
loss  of  blood,  erysipelas,  etc.,  were  the  principal  causes  of  death. 

Partial  excisions  give  a  death-rate  of  about  eight  per  cent  from  all 
causes. 

During  the  operation  the  entrance  of  air  into  the  veins  of  the  neck 
is  especially  to  be  guarded  against. 

Excision  of  the  Scapula. — This  bone  is  excised  on  account  of  gun- 
shot injuries,  necrosis,  and  morbid  growths. 

The  whole  bone  may  be  removed,  or  its  body,  angles,  and  spine 
may  be  removed  separately.  Its  contiguous  anatomy  is  extensive,  but 
not  of  the  dangerous  character  of  that  associated  with  the  clavicle. 
To  its  spine,  borders,  and  surfaces  numerous  and  powerful  muscles  are 
attached. 

At  the  upper  border  are  found  the  supra-scapular  vessels  and 
nerves  ;  the  posterior  scapular  artery  passes  down  its  vertebral  bor- 
der ;  while  at  the  axillary  border  the  subscapular,  and  dorsalis  scap- 
ula? arteries,  and  even  the  axillary 
artery  itself,  and  the  brachial  plex- 
us, are  in  close  connection  with  the 
bone. 

Excision  of  the  entire  Scapula 
(Fig.  249). — Make  an  incision  from 
the  tip  of  the  acromion  process  along 
the  spine  to  the  posterior  border  of 
the  scapula,  a,  b.  Join  it  by  a  second 
incision  extending  from  near  the 
middle  of  the  spine,  c,  to  the  inferior 
angle  of  the  bone;  dissect  up  and 
turn  aside  the  flaps  thus  formed. 

Divide  the  attachments   of    the 
deltoid  and  trapezius ;   disarticulate 
the  acromio-clavicular   articulation  ; 
secure  the  subscapular  artery  ;  divide 
the  ligaments  and  tendons  around  the  glenoid  cavity  ;  raise  the  cora- 
coid  process  and  carefully  sever  its  ligaments  and  muscular  attach- 
ments ;  raise  the  scapula  by  the  inferior  angle  and  divide  its  remain- 


Fig.  249. — Excision  of  entire  scaoula. 


OPERATIONS   ON   BONES. 


183 


ing  muscular  attachments  with  a  knife  or  strong  pair  of  scissors,  care- 
fully avoiding  the  subscapular  and  posterior  scapular  vessels  ;  tie  all 
the  bleeding  points  ;  wash  with  an  antiseptic  solution  ;  thoroughly 
drain  and  close  the  wound,  and  dress  antiseptically.  Sir  W.  Fergu- 
son and  Mr.  Pollock  thought  it  better  to  raise  the  vertebral  border  of 
the  scapula  first,  that  the  subscapular  artery  might  be  the  better  con- 
trolled. Spence  thought  that  the  anterior  angle  should  be  raised  first, 
the  better  to  control  the  subclavian  artery.  All  danger  of  hemorrhage 
during  the  operation  is  easily  obviated  by  pressure  on  the  subclavian 
artery  above  the  clavicle  by  means  of  a  short  crutch  or  a  large  key, 
also  by  direct  pressure  on  the  subclavian  after  the  anterior  angle  of 
the  scapula  is  elevated. 

The  results  of  this  operation  are  good.  Of  sixty-six  cases  of  com- 
plete excision,  fourteen  died.  The 
rate  of  mortality  from  the  opera- 
tion is  about  eight  per  cent ;  it  is 
greater  when  due  to  traumatic 
causes  than  when  due  to  disease. 

Excision  of  the  Body  of  the 
Scapula  (Fig.  250). — Make  an  in- 
cision the  whole  length  of  the 
spine,  a,  b  ;  begin  a  second  incis- 
ion at  the  posterior  superior  spine, 
and  carry  it  along  the  posterior 
border  of  the  bone  to  its  inferior 
angle,  c,  d ;  dissect  the  resulting 
triangular  flaps  from  their  corre- 
sponding fossae,  carefully  avoiding 
the  supra  -  scapular  artery  and 
nerve  ;  saw  through  the  acromion 
process  close  to  the  body,  divide 
the  muscles  attached  to  the  anterior  and  superior  borders  of  the 
scapula  ;  raise  the  bone  upward  and  saw  through  the  anterior  superior 
angle  behind  the  coracoid  process,  turn  the  bone  outward  and  sever 
its  posterior  connections  with  a  knife  or  strong  scissors. 

The  Acromion  Process  and  Angles  of  the  Scapula  may  be  sepa- 
rately removed.  To  remove  the  former,  make  an  incision,  which 
may  be  curved  if  necessary,  along  its  upper  border — expose  tin; 
process,  divide  the  muscles  attached  to  it,  and  with  a  pair  of 
bone-forceps  remove  the  desired  amount.  This  process  can  be  re- 
moved by  making  a  curved  or  crucial   incision  over  it  ;  exposing  its 

upper  surface,  dividing  the  muscles  connected  therewith,  disarticulat- 
ing the  clavicle,  and  removing  the  requisite  amount  with  a  chain- 
saw. 

To  remove  an   angle,  make  a  V-shaped   incision  over  it,  disseot  off 


Fig.  250. — Excision  of  body  of  scapula. 


li 


OPERATIVE   SURGERY. 


Fig.  251.— Subperiosteal  excision. 


the  flaps,  separate  the  muscles  from  the  hone,  and  divide  the  exposed 
portion  with  the  bone-forceps. 

Subperiosteal  Excision  of  the  Scapula  (Oilier)  (Fig.  251).—  Make 
an  incision  from  the  outer  extremity  of  the  acromion  process  along  the 

spine  of  the  scapula  to  its  posterior 
0  border,  a,   b.     Make  a  second   in- 

cision from  the  posterior  superior 
angle  of  the  scapula  along  its  poste- 
rior border,  crossing  the  former,  to 
the  inferior  angle,  c,  b,  d.  Sever 
the  muscular  attachments  to  the 
acromion  process  and  spine  ;  divide 
the  periosteum  at  the  posterior 
border  of  the  scapula  between  the 
attachments  of  the  rhomboideus 
major  and  infra-spinatus  muscles, 
and  separate  it  from  the  infra- spi- 
nous fossa.  Eemove  the  muscular 
attachments  of  the  superior  border 
of  the  scapula.  The  periosteum  is 
then  raised  from  the  supra-spinous 
fossa,  being  careful  to  not  injure  the  supra-scapular  vessels,  as  they 
pass  in  close  contact  with  the  supra-scapular  notch  ;  disconnect  the 
muscles  attached  to  the  borders  of  the  scapula,  closely  hugging  the  bone; 
raise  it  upward  by  its  inferior  angle,  denude  the  subscapular  fossa, 
leaving  its  periosteum  connected  with  the  subscapularis  muscle ;  lib- 
erate the  posterior  border,  allowing  its  cartilaginous  portion  to  remain 
— when  present.  Turn  the  bone  upward  and  forward,  and  remove 
the  remaining  periosteum  from  its  under  surface  up  to  the  neck  of  the 
scapula,  and  divide  the  neck  with  the  chain-saw.  If  the  extent  of  the 
disease  will  not  permit  this,  the  neck  can  be  enucleated,  leaving  the 
ligaments  connected  with  the  periosteum. 

Excision  for  Malignant  Groivths. — Make  an  incision  from  the  pos- 
terior superior  angle  to  the  lower  border  of  the  tumor,  carrying  it 
downward,  forward,  and  inward,  with  the  convexity  posteriorly.  A 
second  incision,  beginning  five  inches  or  so  in  front  of  the  preceding 
incision,  is  carried  downward  and  backward,  crossing  the  other  at  or 
near  its  middle,  and  terminating  at  the  lower  border  of  the  growth. 
The  flaps  are  then  reflected  from  the  tumor,  and  the  muscular  at- 
tachments are  separated  from  the  spine  of  the  scapula,  and  the  acro- 
mion process  sawn  through  behind  the  clavicle ;  expose  the  su- 
perior and  posterior  borders  of  the  scapula,  and  free  them  of  their 
attachments  ;  raise  the  bone  upward  and  forward  by  its  posterior 
border,  and  sever  the  serratus  magnus  muscle  from  it ;  free  the 
axillary  border,  and  divide  the  neck  of  the  bone  with  a  saw,  if  prac- 


OPERATIONS   ON   BONES. 


185 


ticable.     When  necessary,  complete  the  entire  removal  by  disarticula- 
tion. 

It  is  not  possible  to  lay  down  definite  rules  to  govern  the  number, 
extent,  or  direction  of  the  incisions  ;  each  of  these  must  depend  on 
the  size  and  situation  of  the  growth,  together  with  the  amount  of 
bone  to  be  removed,  and  the  ease  and  safety  with  which  it  can  be 
done.  After  the  removal,  arrest  hemorrhage,  provide  good  drainage, 
unite  the  cut  surfaces,  and  dress  antiseptically. 

The  results  of  the  operation  are  flattering  :  nineteen  per  cent  died 
from  entire  removal  of  the  scapula  due  to  disease.  The  mortality  was 
twenty-six  per  cent  in  partial  excisions  for  disease,  and  about  twenty 
per  cent  when  done  for  injury. 

Excision  of  the  Humerus. — The  humerus  can  be  removed  entirely 
or  in  part. 

The  Important  Associated  Anatomy. — The  insertions  of  the  mus- 
cles acting  upon  the  upper  end  of  the  bone,  the  course  of  the  superior 
profunda  and  circumflex  arteries,  the  relations  of  the  circumflex, 
musculo-spiral,  and  ulnar  nerves ;  the  points  of  insertion  of  the  liga- 
ments of  the  joints,  together  with  the 
connections  of  the  important  muscles, 
must  be  carefully  considered  before 
attempting  the  operation.  This  oper- 
ation has  been  done  for  the  relief  of 
old  dislocations,  caries,  necrosis,  gun- 
shot injuries,  arthritis,  malignant  dis- 
ease, etc. 

Excision  of  the  Upper  End  of  the 
Humerus  (Langenbeck).  — Place  the 
patient  upon  the  back,  with  the  shoul- 
ders raised ;  make  an  incision  about 
four  inches  in  length  downward  from 
the  anterior  border  of  the  acromion 
process,  close  to  its  articulation  with 
the  clavicle,  in  the  line  of  the  bicipi- 
tal groove  (Fig.  252).  The  bone  at 
this  region  is  quite  superficial  ;  liber- 
ate the  long  head  of  the  biceps  tendon 
from  the  groove,  by  carrying  the  point 
of  the  knife  upward  in  the  groove  at 
the  outer  Bide,  through  the  capsule  to 
the  acromion,  and  raise  Hie  tendon  out 
of  the  groove  (Fig.  253)  :  rotate  the 
arm  outward  and  divide  the  subscapu- 
laris  tendon  and  inner  portion  of  the 
capsule;   thou   rotate  the  arm  inward,  and  cut  the  external  rotators 


Fio.  252. — Excision  of  upper  end  of 
humerus. 


186 


OPERATIVE   SURGERY. 


and  posterior  portion  of  the  capsule  (Fig.  254)  ;  force  the  head  of  the 
bone  through  the  opening  in  the  soft  parts  (Fig.  255),  seize  it  with  a 
strong  pair  of  forceps,  divide  the  inferior  portion  of  the  capsule,  and 
remove  the  head  of  the  bone  with  a  chain-  or  a  small  straight  saw. 


Fig.  253. — Raisin";  tendon. 


Fig.  255. 


Fig.  254. — Attachments  to  tuberosities  of  humerus. 
a.  Teres  minor  muscle,  b.  Infra-spinatus  mus- 
cle, c.  Supra-spinatus  muscle.  d.  Subscapu- 
laris  muscle.  /.  Tendon  of  long  head  of  biceps 
muscle  in  the  groove. 


Subperiosteal  Excision  of  Head  of 
Humerus  (Langenbeck).  —  Expose  the 
bicipital  groove  and  split  up  the  capsu- 
lar ligament  as  in  the  preceding  opera- 
tion. Divide  and  raise  the  periosteum 
from  the  inner  border  of  the  bicipital 
groove,  passing  inward  and  separating  it  together  with  the  subscapu- 
laris  and  the  fibrous  capsule  from  the  lesser  tuberosity."  Eotate  the 
humerus  outward  and  complete  the  separation  to  the  required  extent 
with  the  elevator  and  knife  ;  rotate  the  arm  inward,  displace  the  ten- 
don of  the  biceps  to  the  inner  side  of  the  head  of  the  humerus,  and 
separate  the  periosteum  from  it  in  connection  with  the  capsule  and 
the  insertions  of  the  external  rotators,  being  very  careful  not  to  sever 
its  connection  with  the  bone  below.     To  force  the  head  of  the  bone 


-Sawing  head  of  hu- 
merus. 


OPERATIONS   OX   BOXES. 


187 


through  the  external  opening  is  practically  impossible  without  de- 
stroying the  periosteal  connections ;  it  is  necessary,  therefore,  to  divide 
the  bone  in  its  position  with  a  chain  or  nar- 
row-bladed  saw. 

Partial  removal  of  the  upper  extremity  of 
the  humerus  is  often  necessary  on  account  of 
disease  or  injury.  The  variety  and  extent  of 
the  incisions  to  reach  the  part  must  be  gov- 
erned by  the  amount  of  the  disease. 

Either  the  vertical,  V-or  U-shaped  incision 
can  be  selected  as  best  suits  the  exigencies  of 
the  case. 

Excision  of  the  Glenoid  Angle  of  the  Scap- 
ula.— This  operation  is  only  applicable  to 
those  conditions  of  injury  or  disease  that  are 
limited  to  the  glenoid  articular  surface  of  the 
scapula.  If  a  penetrating  wound  exist,  its 
course  should  be  followed  to  reach  the  bone  ; 
if  not,  then  a  curved  incision  is  made  around 
the  posterior  border  of  the  acromion  process 
dividing  the  fibers  of  the  deltoid,  and  expos- 
ing the  posterior  and  upper  surface  of  the 
joint  (Fig.  256).  A  second  incision  is  then 
made,  commencing  at  the  center  of  this  one, 
at  the  upper  margin  of  the  glenoid  cavity, 
and,  passing  downward  through  the  capsule, 

upon  the  center  of  the  greater  tuberosity,  between  the  tendons  of 
the  supra-  and  infra-spinatus  muscles  through  the  deltoid  in  the  di- 
rection of  its  fibers.  Open  the  wound  widely  by  means  of  retractors 
and  divide  the  tendons  of  the  biceps  at  their  origin  ;  separate  the 
periosteum  from  around  the  neck  of  the  scapula,  if  possible  leaving 
the  attachments  of  the  capsular  ligaments.  Cut  through  the  exposed 
bone  with  a  chain-saw,  and  remove  it  carefully  to  avoid  injury  to  the 
periosteum. 

Excision  of  the  Shaft  of  the  Humerus. — In  this  operation,  unless 
great  caution  is  observed,  the  musculo-spiral  nerve  and  the  superior 
profunda  artery  will  be  injured  in  their  cour£e  along  the  musculo- 
Bpiral  groove,  as  well  also  as  the  circumflex  nerves  and  vessels,  if  the 
incision  be  extended  (Fig.  257)  upward  too  far.  The  upper  portion  of 
the  shaft  is  easily  exposed  by  making  an  incision  of  sufficient  length 
through  the  outer  surface  of  the  deltoid,  commencing  at  its  lower 
third  and  dividing  it  carefully  upward,  to  avoid  the  circumflex  nerve 
andarterj  ;  the  bone  is  then  denuded  of  its  periosteum, or  the  morbid 
growth  connected  with  it.  i-  circumscribed  and  removed.  If  the  lower 
portion  of  the  shaft  i.s  to  be  operated  upon,  make  the  incision  along 


Fig.  256. — Excision  of  gle- 
noid angle. 


188 


OPERATIVE   SURGERY. 


the  outer  border  of  the  brachialis  anticus  muscle,  carefully  avoiding 
the  musculo-spiral  nerve  ;  expose  the  bone  and  remove  it  as  before. 


Fig.  257. — Musculo-spiral  and  circum- 
flex nerves. 


Fig.  258. — Relation  of  ulnar  nerve 
to  elbow-joint,  a.  Inner  condyle 
of  humerus,  b.  Ulnar  nerve,  c. 
Olecranon  process. 


Excision  of  the  Lower  Extremity  of  the  Humerus. — The  relation 
of  the  ulnar  nerve  (Fig.  258,  b)  to  the  internal  condyle,  a,  and  of  the 
brachial  artery  to  the  anterior  surface,  must  not  be  forgotten.  Make 
an  incision  on  the  posterior  and  external  surface  of  sufficient  length  to 
thoroughly  expose  the  bone  ;  elevate  the  periosteum  and  divide  the 
bone  with  a  chain-saw ;  pull  the  upper  end  of  the  fragment  down- 
ward and  disarticulate  it  from  without  inward. 

If  it  be  necessary  to  remove  the  entire  humerus,  make  incisions  as 
if  to  remove  the  upper  and  lower  portions,  observing  the  same  precau- 
tions relative  to  the  anatomy  of  these  parts.  The  musculo-spiral 
nerve  in  this  operation  is  to  be  most  cautiously  avoided. 

In  all  the  preceding  operations,  substantially  the  same  after-treat- 
ment is  required  :  arrest  the  hemorrhage,  irrigate  the  exposed  surfaces 
with  an  antiseptic  solution,  provide  drainage,  close  the  lips  of  the 
wound,  envelop  the  entire  limb  with  antiseptic  dressing,  and  place  it 


OPERATIONS   ON   BONES. 


18(J 


upon  a  splint  affording  an  easy  support  at  the 
proper  angle.  Extension  is  often  necessary  to 
maintain  the  limb  at  a  suitable  length  during  the 
healing  process. 

The  results  depend  much  upon  the  nature  of 
the  injury,  the  period  of  the  operation,  and  the 
employment  of  antiseptics.  Of  gun-shot  wounds 
of  the  shoulder-joint  requiring  excision,  about 
thirty-five  per  cent  die  ;  the  rate  of  mortality  be- 
ing increased  when  the  inflammatory  stage  exists 
at  the  time  of  operation.  When  excised  for  dis- 
ease eighty-two  per  cent  recovered,  of  which  the 
limb  was  useful  in  three  fourths  of  the  cases. 
Thorough  antisepsis  will  lessen  this  death-rate  at 
least  fifty  per  cent. 

Excision   of   the  Elbow-Joint   (Hiiter). — With 
the  forearm  extended  make  a  slightly  curved  in- 
cision about  an  inch  in  length  down  upon  the  tip  of  the  internal 
condyle,   and  carefully  separate  the  muscular  and   ligamentous  at- 


Fig.  259.— FIUter's  in- 
cision. 


Fig.  260. — Ligaments  of  elbow-joint. 


I    Mi  I  \ 

Fig.  261. — Langcn-    Fig.  262.— Liston'o 
beck's  incision.  Incision. 

tachments  to  the  condyle  ;  make  a 
second  longitudinal  incision  from  three 
to  four  inches  in  length  down  to  the 
head  of  the  radius  (Fig.  859).  Draw 
Bflide  the  sofl  pari  -  and  cut  the  exter- 
nal lateral  and  orbicular  ligaments  (fig. 


190  OPERATIVE   SURGERY. 

260).  Expose  the  head  of  the  radius  and  cut  it  off  with  a  saw  or 
bone-forceps.  Separate  the  capsular  ligament  from  its  attachments 
on  the  anterior  and  posterior  surfaces  of  the  humerus  ;  force  the  ex- 
tremity of  the  bone  out  of  the  external  wound.  This  movement 
admits  of  its  division,  and  at  the  same  time  raises  the  ulnar  nerve 
from  its  bed  and  away  from  the  bone.  Saw  off  the  lower  end  of  the 
humerus,  and  carefully  expose  and  remove  the  olecranon. 

Subperiosteal  Excision  of  Elbotv-Joint  (Langenbeck). — Make  a  lon- 
gitudinal incision  down  to  the  bone,  three  or  four  inches  in  length,  a 
little  to  the  inner  side  of  the  middle  of  the  olecranon  process,  about  two 
thirds  of  its  length  extending  below  the  tip  of  the  olecranon,  carefully 
avoiding  the  ulnar  nerve  (Fig.  261).  Eemove  the  periosteum  from  the 
portion  of  the  olecranon  process  and  ulna  at  the  inner  side  of  the  incis- 
ion. Separate  by  short  parallel  incisions  the  attachments  of  the  inner 
half  of  the  triceps  tendon  to  the  olecranon  process.  Push  the  tissues 
at  the  internal  condyle,  together  with  the  ulnar  nerve,  inward  toward 
the  tip  of  the  condyle,  and  elevate  the  periosteum  from  the  inner  con- 
dyle sufficiently  to  separate  the  internal  lateral  ligaments  and  the  at- 
tachments of  the  muscles  from  the  bone,  and  leave  them  connected 
with  the  periosteum.  The  liberated  tissues  are  now  permitted  to 
return  to  their  former  position,  and  the  outer  portion  of  the  tendon 
of  the  triceps  is  drawn  outward  and  disconnected  from  the  olecranon 
process  by  short  transverse  incisions,  closely  hugging  the  bone  and 
allowing  it  to  remain  continuous  with  the  periosteum  which  is  reflect- 
ed upon  the  inner  surface  of  the  olecranon  and  shaft  of  the  ulna  ; 
expose  the  external  condyle  by  separating  the  capsular  ligament  at  its 
attachment,  above  the  trochlea  and  capitulum  ;  the  tissues,  including 
the  detached  periosteum  and  tendon  of  the  triceps,  are  separated  well 
from  the  bone  by  retractors.  Flex  the  forearm  and  force  the  extremi- 
ties of  the  bones  through  the  opening  ;  saw  off  the  head  of  the  radius, 
then  the  lower  end  of  the  humerus,  and  finally  the  olecranon  process. 
It  is  necessary  to  remember  in  all  cases  of  excision  about  the  elbow- 
joint,  to  respect  the  insertions  of  important  muscles,  such  as  those  of 
the  brachialis  anticus,  biceps,  triceps,  etc.  To  unnecessarily  destroy 
the  power  of  one  of  these,  is  to  be  guilty  of  an  unpardonable  oversight. 
Variously  formed  incisions,  other  than  the  longitudinal,  have  been 
employed  ;  as  the  H,  with  the  horizontal  portion  corresponding  to  the 
articulation  ;  the  T,  with  the  horizontal  on  a  line  with  the  condyle  ; 
U-shaped  or  semilunar,  with  the  convexity  downward. 

Excision  of  the  Elbow-Joint  by  the  \-  -Shaped  Incision  (Liston,  Fig. 
262). — Flex  the  elbow  to  an  obtuse  angle,  the  operator  facing  its  pos- 
terior surface,  open  the  capsule  between  the  olecranon  process  and  in- 
ternal condyle  by  a  longitudinal  incision  about  four  inches  in  length 
along  the  inner  border  of  the  olecranon,  dissect  and  draw  the  soft 
parts  over  the  internal  condyle  with  the  thumb  (Fig.  263),  increasing 


OPERATIONS   ON   BONES. 


191 


the  flexion  gradually  till  the  condyle  is  fully  exposed,  divide  the  in- 
ternal lateral  ligament,  extend  the  arm  and  carry  a  transverse  incision 


Fig.  2o3. — Exposing  internal  condyle. 

from  the  point  of  articulation  of  the  radius  with  the  humerus  directly 
across  to  the  center  of  the  former  incision. 

The  periosteum  on  the  inner  surface  of  the  olecranon  process  and 
ulna  is  raised  and  left  connected  with  the  tendon  of  the  triceps,  which 
i-  carefully  separated  from  the  bone.  Open  the  flaps  wide  and  divide 
the  external  lateral  ligament,  flex  the  forearm,  and  the  articular  sur- 
faces will  separate.  Seize  and  saw  off  the  lower  extremity  of  the 
humerus,  the  olecranon  process,  and  finally  the  head  of  the  radius. 

Results. — Excision  of  the  elbow-joint  has  been  performed  with 
hk'Ii  good  success  that  its  high  rank  is  thoroughly  established.  Al- 
thongh  when  due  to  injury  the  rate  of  mortality  is  about  twenty  per 
cent,  when  due  to  disease  it  i-  lew  than  eleven  percent.  Partial  excis- 
ions are  followed  bj  better  results,  bo  far  as  motion  ie  concerned,  than 
complete-  excisions. 


192  OPERATIVE   SURGERY. 

It  would  appear  that  the  saving  of  the  synovial  membrane  exerts  a 
more  conservative  influence  upon  the  usefulness  of  the  joint  than  the 
saving  of  bone  ;  provided,  of  course,  that  the  bony  insertions  of  the 
muscles  acting  directly  upon  the  joint  be  respected.  The  amount  of 
bone  removed  will  determine  the  usefulness  of  the  joint.  If  too  little, 
the  movement  will  be  limited  and  insufficient ;  if  too  great,  it  will 
dangle,  and  be  of  little  use  except  for  prehension.  If  the  operation  be 
for  traumatism,  remove  the  fragments  ;  if  for  disease,  remove  the  dis- 
eased portion  ;  in  both  conditions  trim  the  extremities  of  the  bones  so 
as  to  afford  symmetrical  support  to  opposed  bony  surfaces.  The  wounds 
should  be  washed  with  a  suitable  antiseptic  solution,  closed  with  proper 
drainage,  dressed  antiseptically,  and  kept  extended  until  repair  is  be- 
gun ;  when  the  limb  should  from  time  to  time  be  placed  at  various 
angles  for  a  day  or  so.  By  this  course  the  newly  formed  tissue  will 
thereafter  conform  more  readily  to  the  various  movements  of  the  joint. 

Excision  of  the  Ulna. — An  incision  is  made  along  its  posterior  sur- 
face of  sufficient  length  to  expose  the  diseased  bone,  the  periosteum 
is  pushed  aside,  and  section  is  made  at  the  requisite  point  and  the  dis- 
eased bone  is  removed. 

If  it  be  a  partial  excision  of  its  upper  extremity,  expose  that  por- 
tion by  an  incision  in  the  same  line,  as  for  removal  of  the  entire  bone, 
elevate  the  periosteum,  leaving,  if  possible,  the  attachments  of  the 
brachialis  anticus  and  triceps  muscles,  and  avoid  the  ulnar  nerve,  at 
the  inner  condyle. 

Excision  of  the  Radius. — Make  an  incision,  extending  from  the 
styloid  process  of  the  radius,  along  the  outer  border  of  the  anterior 
surface  of  the  forearm  to  the  radio-humeral  articulation,  through  the 
integument  and  fascia.  Seek  the  outer  border  of  the  supinator  longus, 
pass  upAvard,  separating  it  from  the  flexor  longus  pollicis,  and  going 
down  to  the  bone,  divide  the  supinator  brevis,  also  the  periosteum  in 
the  long  axis  of  the  radius  ;  elevate  the  periosteum  ;  divide  the  bone 
in  the  center,  and  remove  each  half  separately.  The  insertion  of  the 
biceps  and  pronator  radii  teres  should  be  carefully  preserved.  If  an 
extremity  of  the  bone  is  to  be  excised,  expose  the  portion  to  be  re- 
moved by  an  incision  made  in  the  same  line  as  the  preceding ;  raise 
the  periosteum  with  equal  caution,  and  remove  the  diseased  portion. 

The  results  of  this  operation  are  good  ;  a  patient  seldom  dies,  and 
fair  use  of  the  extremity  is  secured. 

Excision  of  the  Lower  Extremities  of  the  Bones  of  the  Forearm 
(Bourgary). — Make  an  incision  two  inches  in  length  along  the  inner 
border  of  the  ulna  on  the  dorsal  surface,  from  just  below  the  apex  of 
the  styloid  process  (Fig.  264).  Divide  the  periosteum  at  the  inter- 
space between  the  extensor  and  flexor  carpi  ulnaris  muscles  in  the 
same  line,  and  reflect  it  from  the  dorsum  of  the  bone  inward  to  the 
interosseous  membrane.    A  second  longitudinal  incision  is  made  along 


OPERATIONS   OX   BONES. 


193 


the  outer  side  of  the  radius  from  just  be- 
low the  apex  of  the  styloid  process  two  or 
three  inches  upward ;  the  periosteum  is 
divided  through  the  same  incision,  the  at- 
tachment of  the  supinator  longus  sepa- 
rated, and  the  periosteum  raised  on  the 
dorsal  surface  together  with  the  sheaths 
of  the  extensor  tendons. 

The  periosteum  is  then  elevated  from 
the  like  portions  of  the  palmar  surface 
of  the  lower  ends  of  both  bones  around  to 
the  interosseous  membrane.  Protect  the 
soft  parts  carefully  while  the  bones  are 
being  sawn  through.  The  operation  can 
be  extended  to  the  bones  of  the  carpus  if 
necessary,  by  continuing  the  lateral  incis- 
ions downward. 

Excision  of  the  Wrist-Joint.  —  This 
joint  properly  consists  of  the  radius,  ar- 
ticulated with  the  outer  two  of  the  first 
row  of  carpal  bones.  In  cases  where  ex- 
cision is  necessary,  it  is  not  usual  to  find 
the  disease  or  injury  limited  entirely  to 
these  structures.  It,  therefore,  becomes 
necessary  to  remove  all  bony  structures 
involved,  even  though  they  include  the 

two  rows  of  carpal  and  the  contiguous  extremities  of  the  metacarpal 

bones.  The  intimate  relation  exist- 
ing between  the  carpal  bones  and 
the  continuity  of  their  synovial  sur- 
roundings, renders  them  especially 
liable  to  progressive  disease  as  well 
as  to  inflammatory  processes  (Fig. 
2G5).  They  are  intimately  bound  to- 
gether by  strong  ligaments  admit- 
ting of  but  limited  movement  be- 
tween their  surfaces  (Figs.  266  and 
267).  Since  these  bones  are  in  close 
relation  to  the  tendons  of  important 
muscles,  the  sheaths  of  which  should 
be  scrupulously  preserved  together 
with  themselves,  this  operation  is 
surrounded  with  difficult  and  tedi- 
ous details. 

Pw.  265.— Synovial  membrane*  of  carpus,         All   diseased   or   detached    bone 
i:$ 


Fig.  2G4. — Lateral  incisions. 


194 


OPERATIVE   SURGERY. 


should  be  removed.  If  a  portion  of  a  carpal  bone  be  diseased,  it  is 
better  that  the  entire  bone  be  removed.  The  insertions  of  all  muscles 
acting  on  the  carpus  should  be  preserved,  if  possible. 


Fig.  266. — Ligaments  of  dorsal  surface         Fig.  267.— Ligaments  of  palmar  surface 
of  carpus.  of  carpus. 

A  tendon  is  not  to  be  divided,  except  it  forms  an  insurmountable 
obstacle  to  the  incision  necessary  to  the  removal  of  the  bones,  and  it 
should  afterward  be  sutured.  If  the  tendons  be  divided  at  a  distance 
from  the  immediate  seat  of  the  operation,  and  subsequently  sutured, 
the  chances  of  union  will  be  enhanced.  The  radial  and  ulnar  arteries 
and  the  branches  associated  with  the  carpus  should  be  cautiously 
avoided. 

Complete  Excision  of  the  Wrist-Joint  (Langenbeck). — Place  the 
forearm  and  hand  of  the  patient  with  the  palm  downward  on  a  table 
of  convenient  height  for  the  operator  and  his  assistant.  An  incision  is 
then  made  through  the  integument,  beginning  at  the  middle  of  the 
metacarpal  bone  of  the  index-finger  at  its  ulnar  border,  and  extending 
longitudinally  to  three  fourths  of  an  inch  above  the  lower  extremity 
of  the  radius,  at  its  middle  (Fig.  268).  The  deeper  course  of  the  in- 
cision passes  to  the  radial  side  of  the  extensor  indicis  without  opening 
its  sheath,  upward,  over  the  tendon  of  the  extensor  carpi  radialis 
brevior,  to  the  inner  side  of  its  insertion  ;  then,  if  the  tendons  going 
to  the  index-finger  be  pushed  to  the  ulnar  side,  the  incision  extends 
upward  to  the  beginning  of  the  tendons  of  the  extensor  secundi  inter- 
nodii  pollicis  and  the  extensor  indicis,  dividing  the  lower  portion  of 
the  posterior  annular  ligament.  Draw  the  tissues  apart  with  suitable 
retractors  and  separate  from  the  bone  with  a  periosteal  elevator  the 


OPERATIONS   ON   CONES. 


195 


fibrous  sheaths  of  the  extensors  of  the  carpus  on  the  posterior  surface 
of  the  radius ;  the  insertion  of  the  supinator  longus  muscle,  and  the 
annular  and  capsular 
ligaments  are  then  dis- 
connected and  drawn 
to  the  radial  side  to- 
gether with  the  perios- 
teum ;  the  tendons,  liga- 
ments, and  periosteum 
on  the  posterior  surface 
of  the  ulna  are  sepa- 
rated in  the  same  man- 
ner and  drawn  to  the 
ulnar  side.  Open  well 
the  radio-carpal  joint, 
flex  the  carpus  and  ex- 
pose the  articular  sur- 
faces, and  separate  the 
bones  of  the  first  row 
from  their  connection 
with  each  other,  leaving 
the  periosteum  if  pos- 
sible. Liberate  the  sca- 
phoid from  the  trape- 
zium and  trapezoid, 
the  semilunar  from  the 
os  magnum,  and  the 
cuneiform  from  the  un- 
ciform ;  lift  them  out, 
leaving  their  perios- 
teum— if  possible — to- 
gether with  the  trape- 
zium and  pisiform 
bones.  The  bones  of  the  second  row  are  taken  out  after  severing  the 
connections  between  the  trapezium  and  trapezoid,  and  the  heads  of 
the  metacarpal  bones.  The  extremities  of  the  radius  and  ulna  can 
now  be  forced  through  the  wound,  carefully  exposed  and  sawn  off, 
avoiding  the  radial  and  ulnar  vessels.  The  divided  tendons  should  be 
sutured  and  the  resulting  wound  treated  by  antiseptic  measures.  Con- 
tinuous extension  from  the  fingers  should  be  early  and  constantly  em- 
ployed during  the  after-treatment. 

I'hore  are  other  incisions  intended  to  meet  the  indication  (Lis- 
ter): Begin  the  incision  on  the  dorsal  aspect  of  the  radius,  opposite  the 
styloid  process,  and  carry  it  toward  the  inner  side  of  the  metacarpal 
articulation  of  the  thumb  parallel  with  the  eecundi  internodii  pollicis 


Fig.  268. — a.  Extensor  carpi  radialis  longior.  b.  Extensor 
longus  pollicis.  e.  Extensor  carpi  radialis  brevior.  d. 
Posterior  annular  ligament.    /.  Langeubeek's  incision. 


196 


OPERATIVE   SURGERY. 


Fig.  2G9. — Lister's  incisions. 


tendon  (Fig.  2C9,  a).     When  at  the  radial  border  of  the  second  meta- 
carpal bone,  carry  the  incision  along  one  half  the  length  of  that  bone  ; 

separate  the  soft  parts  on  the  ra- 
dial side,  divide  the  tendon  of 
the  extensor  carpi  radialis  longior 
at  its  insertion,  raise  it,  together 
with  the  extensor  carpi  radialis 
brevior  and  secundi  internodii 
pollicis  tendons,  open  the  wound 
well,  and  disconnect  the  trapezi- 
um from  the  remaining  bones, 
which  are  to  be  taken  away.  Ex- 
tend the  carpus  and  separate  the 
soft  parts  on  the  dorsum  at  the 
ulnar  side  of  the  incision. 

Make  a  second  incision  along 
the  anterior  and  internal  border 
of  the  forearm  on  the  inner  side 
of  the  flexor  carpi  ulnaris,  begin- 
ning it  about  two  inches  above 
the  styloid  process  and  extending 
it  to  the  middle  of  the  metacar- 
pal bone  of  the  little  finger  (Fig. 
269,  b).  Expose  the  dorsum  of  the  ulna,  divide  the  tendon  of  the  ex- 
tensor carpi  ulnaris  at  its  insertion,  separate  it  from  the  groove  in  the 
ulna,  raise  the  extensors  of  the  fingers  from  the  carpus,  leaving  their 
attachments  to  the  radius  intact ;  expose  the  anterior  surface  of  the 
ulna,  hugging  the  bone  closely ;  separate  the  pisiform  bone  with  the 
flexor  carpi  ulnaris  ;  flex  the  hand  and  separate  the  flexor  tendons  in 
the  same  cautious  manner  ;  divide  the  remaining  ligaments  connecting 
the  bones  of  the  forearm  with  the  carpus  ;  separate  the  process  of  the 
unciform  bone,  also  the  carpus  from  the  metacarpus  with  cutting  for- 
ceps ;  expose  the  extremities  of  the  radius  and  ulna  through  the  ulnar 
incision,  remove  with  the  saw  or  forceps  the  diseased  portions,  care- 
fully avoiding  the  grooves  for  the  passage  of  the  tendons ;  remove  the 
trapezium  without  injury  to  the  tendon  of  the  flexor  carpi  radialis. 
All  articular  surfaces  of  bones — metacarpal  bones,  pisiform,  and  be- 
tween lower  extremities  of  radius  and  ulna — should  be  removed,  as 
well  as  all  diseased  portions  of  bone.  Many  other  incisions  may  be 
made  through  which  to  effect  the  removal  of  the  wrist-joint ;  but  only 
such  as  admit  of  it  being  done  through  longitudinal  incisions  are  ad- 
visable, since  transverse  incisions  may  sacrifice  the  tendons  which  im- 
part usefulness  to  the  remaining  portion  of  the  carpus. 

All  hemorrhage  having  ceased,  suture  the  divided  tendons,  close 
the  wound,  allowing  the  most  dependent  incision  to  remain  open  for 


OPERATIONS   ON   BONES. 


197 


drainage.  Envelop  the  limb  in  antiseptic  dressings,  causing  the  whole 
to  be  properly  supported  by  a  splint.  The  subsequent  treatment  con- 
sists in  cleanliness,  extension,  and  passive  motion. 

Results. — Ten  per  cent  die  after  excision  for  disease,  and  fifteen 
per  cent  for  gun-shot  injuries  without  antiseptic  treatment.  In  about 
thirty-three  per  cent  of  those  who  recover,  the  operation  has  been  of 
no  service  ;  in  about  eleven  per  cent,  entirely  satisfactory  ;  in  the  re- 
mainder, useful.  The  prognosis  for  usefulness  is  better  when  excision 
is  performed  for  injury  than  for  disease. 

Excision  of  the  Metacarpophalangeal  Joints. — This  operation  can 
readily  be  done  by  making  an  incision  about  one  inch  and  a  half  in 
length  at  one  side  of  the  extensor  tendons  and  along  the  dorsum  of 
the  bones  composing  the  joint.  The  tissues  in  contact  with  the  bone 
are  carefully  raised  and  turned  aside,  the  joint  exposed,  and  the  re- 
quisite amount  of  bone  removed  by  the  chain-saw,  cutting  forceps,  or 
dental  engine. 

Excision  of  the  Phalangeal  Joints. — These  articulations  may  be  ap- 
proached either  through  a  longitudinal  incision  made  along  the  side 
of  the  joint,  or  by  a  curved  incision  at  the  same  situation  with  the 
convexity  downward.  In  either  instance  separate  the  tissues  carefully 
down  to  the  extremities  of  the  bones,  which,  when  properly  exposed, 
can  be  caused  to  protrude  through  the  incision  by  lateral  flexion  and 
the  extremities  can  then  be  removed. 

The  after-treatment  consists  in  placing  the  fingers  in  an  immov- 
able position  properly  protected  by  an  antiseptic  dressing,  and  when 
repair  begins  passive  motion  is  made  and  continued  until  the  recovery 
is  complete. 

Excision  of  the  Joints  of  the  Lower  Extremities.— The  phalangeal 
joints  of  the  tarsus  are  removed  in  a  similar  manner  to  those  of  the 
upper  extremity. 

The  Metatarso-phalangcalJoints  are  removed  through  longitudinal 
incisions,  made  over  the  dorsal  surface  of  the  bones  constituting  the 
joints,  at  either  side  of  the  extensor  tendons,  which  are  pushed  aside 
together  with  the  remaining  surrounding  soft  parts,  the  bones  ex- 
posed, and  their  extrem- 
ities severed  by  the  chain- 
saw  or  bone-forceps.  The 
removal  of  the  metatarso- 
phalangeal articulation 
of  the  great  toe  can  be 
and  often  is  done  by  a 
different  method.  Make; 
a  curved  incision  with 
the  convexity  downward, 
of    sufficient    length    to  Via.  270.— IT-  haped  Ei 


198 


OPERATIVE   SURGERY. 


freely  expose  the  bones  to  be  removed,  at  the  inner  side  of  the  joint, 
its  center  corresponding  to  the  joint  center  (Fig.  270).  Dissect  the 
soft  parts  from  around  the  bones,  carefully  pushing  aside  the  tendons ; 
expose  and  remove  the  necessary  amount  of  the  articulation  with  a 
chain-saw  or  forceps.  If  the  operation  be  done  for  the  correction  of 
the  deformity  caused  by  prominence  of  the  head  of  the  metatarsal 
bone,  enough  bone  should  be  removed  from  its  extremity  to  permit 
the  easy  return  of  the  displaced  toe  to  its  natural  position  ;  where  it 
is  to  be  retained  quietly  till  repair  is  well  advanced,  and  then  passive 
motion  is  to  be  commenced. 

The  Tarso-metatarsal  Joints  can  be  excised  through  a  straight  in- 
cision or  by  raising  a  semilunar  flap  over  their  dorsal  surfaces,  avoid- 
ing division  of  the  extensor  tendons,  which  are  raised  and  pushed 
aside,  while  the  dorsal  ligaments  connecting  the  bones  are  divided  and 
the  joint  cavity  exposed  by  forced  flexion,  after  which  the  bones  of 
the  distal  row  can  be  divided  with  a  saw  or  bone-forceps.  The  corre- 
sponding extremities  of  the  tarsal  bones  can  be  treated  likewise. 

Tarsal  Joints. — When  separate  tarsal  joints  become  involved  by 
disease  or  traumatic  violence,  they  can  be  removed  by  making  an  in- 
cision over  the  injured  or  diseased  portions,  often  following  in  the 
line  of  the  course  of  the  violence,  or  in  the  tracks  of  sinuses  leading 
from  the  disease. 

This  treatment  is,  however,  better  adapted  to  those  joints  having  a 
limited  synovial  membrane,  than  to  those  where  that  membrane  ex- 
tends between  several  contiguous  bone  surfaces  ;  in  the  latter  case  it 
is  often  better  to  remove  the  bones  entire  by  aid  of  the  chisel,  saw,  or 
gouge.  In  either  instance  curved  incisions  are  preferable,  provided 
they  do  not  divide  important  tendons  and  vessels. 

Excision  of  the  Calcaneum. — It  is  important  that  as  much  as  pos- 
sible of  this  bone  be  saved,  as  it  forms  the  posterior  pillar  of  the  arch 
of  the  foot,  and  also  gives  attachment  to  the  tendo  Achillis,  which 
exerts  a  powerful  influence  in  locomotion.  When  gouging  fails  to 
remove  the  diseased  bone,,  excision  becomes  the  final  resort.    A  horse- 


Fig.  271. — Excision  of  os  calcis. 


shoe-shaped  incision  is  begun  a  little  in  front  of  the  calcaneo-cuboid 
articulation  and  carried  around  the  base  of  the  os  calcis  along  the  side 


OPERATIONS   ON   BOXES.  199 

of  the  foot  to  a  corresponding  point  on  the  opposite  side.  This  flap, 
with  the  knife  hugging  the  bone,  is  dissected  up,  exposing  the  entire 
under  surface  of  the  os  calcis  (Fig.  271).  A  second  perpendicular  in- 
cision about  two  inches  in  length  is  then  made  through  the  middle  of 
the  tendo  Achillis  down  to  the  preceding  one  ;  the  resulting  flaps  are 
dissected  off  close  to  the  bone,  and  the  posterior  articulation  between 
the  calcaneum  and  the  astragalus  opened,  the  ligamentous  connections 
severed,  together  with  those  between  it  and  the  contiguous  bones,  the 
os  calcis  taken  away,  and  any  additional  diseased  bone  removed. 

Results. — A  large  majority  of  these  cases  recover  with  useful 
limbs. 

Excision  of  the  Astragalus. — This  is  accomplished  through  a  semi- 
lunar opening,  with  the  convexity  downward,  extending  between  the 
malleoli  in  front.  The  tendons  of  the  extensor  muscles  must  be  care- 
fully pushed  aside  ;  its  ligamentous  connections  with  the  tibia,  fibula, 
and  os  calcis  are  severed,  finally,  those  with  the  scaphoid ;  then,  with 
the  foot  extended,  the  bone  is  pulled  from  its  site  and  the  calcaneum 
placed  in  the  resulting  gap  between  the  malleoli. 

Results. — About  seventy-five  per  cent  of  these  cases  recover  with 
useful  limbs. 

Excision  of  the  Ankle-Joint. — This  articulation  is  a  hinge-joint, 
having  no  lateral  movement,  except  the  foot  is  well  extended,  and 
then  it  is  very  limited.  The  indications  calling  for  the  operation  are 
numerous,  and  should  be  well  considered  before  it  is  attempted.  As 
in  all  excisions  those  incisions  which  best  preserve  the  tendons,  ves- 
sels, nerves,  and  periosteum  are  to  be  adhered  to,  consecpiently  those 
of  a  longitudinal  character  are  the  best  to  be  employed. 

Operation,  Subperiosteal  (Langenbeck). — Make  an  incision,  about 
three  inches  in  length,  along  the  posterior  border  of  the  lower  extrem- 
ity of  the  fibula  down  to  the  bone  (Fig.  272),  carrying  it  forward  in  a 
hooked  shape  around  the  lower  end 
and  then  upward  along  its  ante- 
rior border  about  an  inch.     The 
periosteum   is  reflected  from  the 
bone  together  with  the  tissues  in 
contact  with  it,  thereby  exposing 
the  lower  extremity  of  the  fibula 
without    opening    the    tendinous 
grooves   of   the   peronei    muscles 
(Fig.  273).     The  fibula  is  then  di- 
vided at  the  upper  end  of  the  in-  Fio.  272.— Excision  of  ankle-joint 

i   with  a  narrow  saw,  pulled 
outward,  and  the  ligamentous  attachments  along  it-  inner  border  and 
surf;.  sred  (Fig.  274),  and  the  bone  removed.     An  inoision  is 

then  made  ahout  an  inch  and   a  half   in   length  down  to  the  bone, 


200  OPERATIVE   SUKGERY. 

around  the  lower  end  of  the  inner  malleolus  (Fig.  275).     A  third  and 
vertical  one  is  next  made  about  two  inches  in  length,  down  to  the 

bone  through  the 
center  of  the  tibia, 
connecting  with 
the       semicircular 

'!■    V%  one  ^rs^  ma(^e-  ^he 

triangular  flaps,  in- 

'^  11111     'llfiL.  eluding  the  perios- 

■  H  \1L  ^Jil?li\  teum,    arc    turned 

lm  ir      m  *  ^lil  aside  with  the  ele- 

vator, using  care  to 
1  raise  the  sheaths  of 

all    tendons    from 
1  :  ■  ™  -   b      their  grooves  (Fig. 

276),  and,  pushing 
1     m/m  them     aside,      the 

""  c      tibia  is  divided  at 
A  r  ...  d      the   upper  end   of 

the    cut     with     a 
chain-saw,  the  frag- 
1  '  ment    pulled    out- 

ward with  the  for- 
ceps, freed  from 
the       interosseous 

Fig.  273.— Outer  side  of  ankle,  a.  Tendo  Achillis.  b.  Pe-  membrane,  and  re- 
roneus  longus.  c.  Peroneus  brevis.  d.  Peroneus  tertius.  moved.  If  it  be  ne- 
e.  External  malleolus.     /.  Extensor  longus  digitorum.    g. 

Crucial  ligament,     h.  Extensor  longus  pollicis.  Cessary    to    remove 

the   articular    sur- 
face of  the  astragalus,  it  can  be  done  through  either  incision ;  the 

better,  however,  through  the  internal  one,  on  account  of  the  greater 

amount  of   room.      If  the 

excision  is  to  be  performed 

for  chronic  disease  of  the 

ankle       and       contiguous 

points,  Vogt   recommends, 

with  the  view  of  getting  a 

more  extended  insight  into 

the  diseased  portions,  that  \  ^/iiP 

an  incision  be  made  anteri- 
orly, midway  between  the  MAJ^Jtl 

tibia  and  fibula,  beginning 

about  two  inches  above  the 

articulation    of    the   ankle 

and  extending  downward  to  Fig.  274.— Removing  lower  end  of  fibula. 


OPERATIONS   ON   BOXES. 


201 


the  medio-tarsal  joint  on  the  dorsal  surface  of  the  foot.  The  long 
extensor  tendons  are  carefully  drawn  to  the  inner  side,  the  tendons  of 
the  short  extensor  are  divided  and 
drawn  to  the  outer  side  ;  the  blood- 
vessels carefully  tied  between  two 
ligatures  and  the  capsule  of  the 
joint  opened  by  a  vertical  incis- 
ion :  then  detach  the  anterior  liga- 
ment and  expose  tbe  head  and 
neck  of  the  astragalus.  If  the 
superior  astragalo-scaphoid  liga- 
ment be  divided,  the  anterior  and 

inner  surfaces  of  this  bone  will  be  better  exposed.     A  transverse  in- 
cision is  now  made  at  right  angles  to  the  primary  one,  extending  out- 


Fig.  275. — Internal  incisions. 


Fig.  276. — Inner  side  of  ankle-joint,  a.  Tibialis  anticus  muscle,  b.  Tendo  Achillis. 
c.  Tibialis  posticus  muscle,  d.  Flexor  longus  digitorum.  e.  Flexor  longus  pollieis.  f. 
Posterior  tibial  artery,     g.  Tuberosity  of  scaphoid  bone. 

ward  to  the  tip  of  the  external  malleolus,  leaving  the  tendons  behind 
it  intact.  Divide  the  three  fasciculi  of  the  external  lateral  ligament 
close  to  the  malleolus,  also  cut  the  interosseous  or  internal  calcaneo- 
astragaloid  ligament,  force  the  articular  surface  of  the  astragalus  out- 
ward, seize  it  with  lion-tooth  forceps,  separate  its  remaining  connec- 
tions, and  remove  it.  All  diseased  portions  can  now  be  easily  exam- 
ined and  removed  with  a  minimum  degree  of  disturbance  of  the 
healthy  tfssui 

The  method  recently  practiced  by  Busch  is  a  very  ingenious  one, 
serving  as  it  does  to  remove  the  diseased  joint  without  impairing  its 
tendons  or  their  sheaths.      It.   is   open   to  the  objection,  however,  of 


202  OPERATIVE   SURGERY. 

weakening  the  arch  of  the  foot,  on  account  of  the  division  of  the  long 
calcaneocuboid  ligament  and  the  plantar  fascia. 

BuscWs  Operation. — An  incision  is  made  down  to  the  bone,  across 
the  sole  of  the  foot,  from  one  malleolus  to  the  other ;  the  sides  of  the 
joint  are  exposed  by  drawing  the  tissues  forward.  The  os  calcis  is  now 
sawn  through  from  below  upward  and  forward  to  the  anterior  margin 
of  the  calcaneo-astragaloid  articulation,  and  pulled  backward  after  the 
division  of  the  opposing  ligamentous  structures.  The  entire  astragalus 
can  now  be  removed  through  the  opening,  and  also  the  lower  extremi- 
ties of  the  tibia  and  fibula. 

After  the  removal  of  the  dead  bone  and  the  establishment  of  good 
drainage,  the  fragments  of  the  os  calcis  are  placed  in  position  and 
held  there  by  silver  wire.  The  wound  should  be  dressed  antiseptically 
and  no  weight  allowed  upon  the  foot  until  the  tissues  are  firmly 
united. 

The  after-treatment  for  excision  of  the  ankle-joint  consists  in  ap- 
plying an  immovable  dressing  around  the  joint  under  antiseptic  pre- 
cautions. 

Results. — "When  done  for  disease,  about  ten  per  cent  die  ;  for  gun- 
shot wounds,  about  twenty-seven  per  cent ;  for  other  injuries,  about 
thirteen  per  cent.  The  results  are  better  from  complete  than  from 
partial  excision. 

The  prognosis  for  life  is  most  favorable  between  one  and  fifteen 
years  of  age ;  most  unfavorable  between  thirty  and  forty  years.  A 
large  proportion  of  the  recoveries  from  this  operation  results  in  a  more 
or  less  useful  limb  ;  about  nine  per  cent  being  useless. 

Excision  of  the  Bones  of  the  Leg. — If  it  be  desired  to  remove,  by 
excision  or  otherwise,  portions  of  either  of  the  bones  of  the  leg,  the 
external  incision  is  governed,  as  to  its  location  and  extent,  by  the 
situation  and  degree  of  the  injury  or  disease  of  the  bone.  The  bone 
should,  however,  be  reached  by  the  shortest  course,  which  usually  is 
betiveen  the  individual  muscles,  rather  than  through  their  structures. 
After  its  removal,  which  should  always  be  subperiosteal,  the  limb  must 
be  so  confined  as  to  permit  the  new  structure,  when  completed,  to  ful- 
fill the  functions  of  its  predecessor.  The  patient  must  not  be  per- 
mitted to  bear  weight  on  the  limb  till  the  new  bone  becomes  firm, 
else  distortion  or  fracture  will  occur. 

Excision  of  the  Knee-Joint— This  joint  can  be  excised  with  com- 
parative safety  to  the  patient,  and  with  a  fair  prospect  of  recovery 
with  a  useful  limb.  As  in  the  preceding,  the  nature  of  the  cause  de- 
manding the  operation  exercises  a  marked  influence  on  the  result. 

Results. — The  mortality,  when  due  to  disease,  is  about  thirty  per 
cent ;  when  dependent  upon  injury,  about  forty  per  cent ;  when 
done  with  all  antiseptic  precautions,  the  rate  is  less  than  fifteen  per 
cent. 


OPERATIONS   OX   BONES. 


203 


If  it  be  for  a  gun-shot  injury,  the  mortality  is  increased  to  seventy- 
five  per  cent.  The  age  of  the  patient  is  a  consideration  not  to  be  un- 
derestimated ;  the  results  are  best  from  five  to  ten  years  of  age,  when 
due  to  injury  or  disease ;  fifteen  to  twenty  per  cent  die  when  done  for 
gun-shot  wounds.  Partial  excision  gives  a  higher  rate  than  complete, 
when  due  to  disease.  The  removal  of  about  three  inches  of  bone  in- 
sures the  best  prognosis  for  life.  A  lesser  or  greater  amount  increases 
the  percentage  of  deaths.  The  removal  of  the  patella,  when  not  dis- 
eased, increases  the  rate  of  mortality  slightly.  The  usefulness  of  the 
limb  after  the  operation  can  be  briefly  summed  up  as  follows : 

When  due  to  disease,  fourteen  per  cent  were  perfect,  forty-two 
were  useful,  and  the  remaining  useless,  of  which  eighteen  per  cent 
were  amputated. 

For  injuries,  about  eighteen  per  cent  were  perfect,  about  sixty-five 
per  cent  useful,  and  about  twelve  per  cent  were  amputated. 

When  due  to  gun-shot  injuries,  about  sixty  per  cent  were  useful  and 
twenty-four  per  cent  were  amputated,  the  remaining  not  accounted  for. 

When  done  for  deformity,  nineteen  and  a  half  per  cent  of  the 
results  were  perfect,  and  about  sixty-eight  per  cent  of  the  patients 
had  useful  limbs  ;  the  remainder  not  reported. 

It  ajDpears  that  the  degree  of  usefulness  does  not  depend  upon  the 
amount  of  bone  removed. 

The  removal  of  the  patella  seemed  to  increase  the  degree  of  use- 
fulness of  the  limb.  In  excision  of  the  knee-joint  for  all  causes,  before 
the  growth  of  the  patient  is  completed,  great  care  should  be  taken  to 
preserve  intact,  if  possible,  the  epiphyseal  cartilage,  especially  of  the 
lower  end  of  the  femur  (Fig.  277).    This  precaution  markedly  lessens 


Via.  217. — Epiphyseal  cartilage  and  line  of  section  in  excision  of  knee-joint. 

the  failure  of  the  development  of  the  length  of  the  femur  upon  the 
i-i. I  ride  thereafter,  became  tint)  epiphyseal  j  auction  provides  for 
much  more  than  its  proportionate  share  of  the  growth  of  t  lie  length 
of  the  femur  normallv. 


204  OPERATIVE   SURGERY. 

Contiguous  Anatomy. — The  articular  vessels  and  those  which  oc- 
cupy the  popliteal  space  are  the  ones  to  be  preserved.  The  latter  are 
removed  from  all  danger  by  the  dense  and  unyielding  ligamentum 
posticum  Winslowii.  The  former  can  be  avoided  by  limiting  the  in- 
cisions to  the  space  between  the  origin  and  insertion  of  the  lateral 
ligaments.  There  are  two  well-known  methods  of  excising  this  joint : 
1,  the  non-subperiosteal,  or  the  ordinary  method ;  and  2,  the  sub- 
periosteal. The  former  is  employed  when  the  tissues  are  too  exten- 
sively destroyed  or  diseased  to  admit  of  the  saving  of  the  periosteum. 

Non-subperiosteal  Excision  of  the  Knee- Joint  (Mackenzie). — Flex 


Fig.  278. — Mackenzie's  anterior  curved  incision. 

the  leg  to  a  right  angle  and  make  a  curved  incision,  from  the  pos- 
terior border  and  upper  portion  of  one  condyle,  around  to  the  same 
point  on  the  outer,  with  the  convexity  downward  and  correspond- 
ing to  the  insertion  of  the  ligamentum  patellae  (Fig.  278).  This  in- 
cision divides  the  tissues  down  to  and  opens  the  anterior  portion  of 
the  capsular  ligament.  The  limb  should  now  be  still  more  strongly 
flexed  and  the  lateral  and  crucial  ligaments  divided.  A  retractor 
is  then  passed  between  the  ligamentum  posticum  Winslowii  and  the 
posterior  surface  of  the  femur,  the  bone  pushed  forward  and  cut  off 
on  a  line  parallel  with  the  articular  surface,  provided  the  extent  of 
the  diseased  bone  will  admit  of  it.  The  head  of  the  tibia  is  then 
treated  in  the  same  manner,  being  careful  to  avoid  the  articulation  of 
the  fibula. 

In  this  operation  it  is  better  to  remove  the  patella,  since  its  means 
of  attachment  (the  ligamentum  patellae)  has  been  severed.  All  in- 
flamed or  degenerated  synovial  membrane  should  be  dissected  away. 

The  bony  surfaces  should  now  be  united  by  passing  two  annealed 
iron  or  silver  wires  anteriorly  through  to  their  posterior  borders.  The 
wound  is  then  washed  with  the  strong  carbolic  or  a  bichloride  solu- 


OPERATIONS   OX   BONES. 


205 


Fig.  279. — Corresponding 
lines  of  division. 


tion  and  a  drainage-tube  passed  from  side  to 

side  through  the  joint  behind  the  bones  ;  the 

whole  enveloped  in  the  antiseptic  dressing, 

and  the  limb  immovably  fixed  in  a  bracketed 

plaster  splint,  and  properly  suspended.     In 

sawing  through  the  exposed  extremities  of 

either  bone,  the  line  of  incision  can  be  made 

to  include  the  whole  of  the  diseased  osseous 

tissue.     If  carious  bone  or  an  abscess  cavity 

extend  in  an  isolated  manner  into  the  sawn 

extremity  of  the  femur  or  tibia,  it  can  be 

scooped  out  and  the  resulting  cavity  drained 

by  making  an  opening  through  its  bottom 

with  a  boue-drill  to  the  external  surface  of 

the   limb,    thereby   saving   the  surrounding 

healthy  bone-tissue  and  contributing  to  the 

length  of   the  diseased  limb.     Deeply  con- 
gested   cancellous 
i~  bone -tissue    should 

be  preserved  if  to 
remove  it  be  to  im- 
pair the  epiphyseal 

cartilage,  since  it  not  infrequently  makes  a 
good  recovery,  but  offers  in  addition  thereto 
the  only  opportunity  of  preserving  the  nor- 
mal growth  of  the  femur.  The  line  of  sec- 
tion through  the  bone  last  sawn  must  corre- 
spond in  direction  to,  and  be  parallel  with, 
the  line  of  section  through  the  bone  to 
which  its  sawn  surface  is  to  be  applied  (Fig. 
279),  otherwise  the  union  of  the  sawn  sur- 
faces will  cause  an  angular  deformity.  This 
applies  more  particularly  to  those  cases  where 
anchylosis  in  the  straight  position  is  sought. 
If  for  any  reason  it  be  thought  better  to  an- 
chylose  the  limb  with  slight  flexion,  then  the 
thicker  portion  should  betaken  from  the  pos- 
terior parts  of  the  bones. 

Subperiosteal     Excision     of    Knee-Joint 
(Lan  gen  beck). — Extend  the  limb  and  make 
a  curved  incision  on  the  inner  side  five  or  six 
inches  in   length,  with  tin-  convexity  down- 
ward, corresponding  to  the  po  terior  border  of  the  condyles,  and  its 

center  to  t  he  line  of  the  art iculation,  commencing  at  the  inn<  r  border 

of  the  rectus  femorie  and  terminating  below  at  the  crest  of  the  tibia 


i  j<; 


280. — Lanqcnbeck's  in- 

'•i-ion. 


206 


OPERATIVE   SURGERY. 


Fig.  281. — Tendons  at  inner  side  of  knee- 
joint,  a.  Vortus  internus  muscle,  b.  Rec- 
tus femoris  muscle,  c.  Sartorious  muscle. 
d.  Adductor  magnus  muscle,  e.  Gracilis 
muscle,  f.  Semi-membranosus  muscle,  g. 
Semi-tendonous  muscle,  h.  Gastrocne- 
mius muscle. 


(Fig.  280).     If  the  flap  be  now  raised,  the  vastus  internus  muscle  and 
the&tendons  of  the  adductor  magnus  and  sartorius  will  be  seen  (Fig. 

281),  and  should  be  carefully 
avoided.  Divide  the  internal 
lateral  ligament  on  a  line  with 
the  articulation  ;  with  the  peri- 
osteal elevator,  separate  the  cap- 
sular ligament  and  the  perios- 
teum from  the  anterior  and 
posterior  surfaces  of  the  inner 
condyle  of  the  femur,  and  the 
tibia  outward  to  the  median  line 
of  the  bones  together  with  the 
internal  semilunar  cartilage  ; 
flex  the  leg,  then  extend  it 
slowly,  and  at  the  same  time  dis- 
locate the  patella  outward  by 
the  thumb  applied  to  the  inner 
border ;  divide  the  crucial  liga- 
ments, also  the  external  lateral, 
and  the  corresponding  portion 
of  the  capsular  ligament  by  a 
semilunar  incision  carried  a  few 
lines  below  the  tip  of  the  external  condyle.  Remove  the  periosteum  and 
its  associated  tissues  from  the  outer  portion  of  tibia  and  femur,  the 
same  as  at  the  inner  side.  Divide  the  posterior  portion  of  the  capsule 
and  force  the  extremities  of  the  femur  and  tibia  successively  through 
the  wound,  and  saw  them  as  before.  The  patella  remains  unmolested, 
except  it  be  diseased,  when  the  diseased  portion  is  removed  with  a 
gouge,  or  the  bone  can  be  enucleated  from  the  periosteal  surroundings 
by  the  elevator  and  scalpel.  A  small  opening  should  now  be  made  at 
the  outer  and  inner  sides  of  the  joint  posteriorly,  for  the  purpose  of  es- 
tablishing thorough  drainage.  A  drainage-tube  can  be  passed  through 
the  upper  synovial  pouch,  or  firm  compression  be  made  thereon  to 
prevent  the  collection  of  inflammatory  products  within  it.  The  sur- 
faces are  then  cleansed,  all  hemorrhage  arrested,  the  flaps  united,  and 
the  limb  surrounded  by  antiseptic  dressing,  and  immovably  fixed  till 
future  dressings  become  necessary. 

The  Subperiosteal  Excision  of  Oilier  is  made  through  an  incision 
commencing  two  inches  above  and  to  the  outer  side  of  the  patella, 
carried  down  to  its  upper  and  outer  angle,  along  the  outer  border  to 
the  apex  and  to  the  outer  side  of  the  ligamentum  patella?,  below  its 
insertion,  through  the  soft  parts  (Fig.  282).  The  outer  condyle  of  the 
femur  is  denuded  of  its  periosteum  together  with,  the  lateral  and  cap- 
sular ligaments  and  the  outer  head  of  the  gastrocnemius  ;  the  anterior 


OPERATIONS   ON   BOXES.  207 

and  internal  surfaces  of  the  femur  are  denuded,  the  crucial  ligaments 
cut,  patella  displaced  inward  over  the  inner  condyle,  the  leg  is  then 
flexed  and  carried  inward,  causing  the  femur  to  protrude,  when  it  is 
isolated  and  sawn  off.  The  upper  end  of  the  tibia  is  then  denuded  of 
its  periosteum  from  above  downward,  pushed  through 
the  opening  and  likewise  divided.     If  the  patella  be  /       ; 

diseased,  remove  it,  leaving  its  periosteum  behind.  /        j 

Excision  by  a  Transverse  Incision. — Ascertain  the         /         i, 
line  of  junction  of  the  articulation  with  the  limb  ex-      /  / 

tended,  if  the  joint  will  permit ;    make  a  transverse      ;       ;'     )] 
incision  from  one  condyle  directly  across  to  the  other,      >--  \  if" 
passing  across  the  middle   of  the   patella  or  at  its      \        / 
apex  ;  if  the  former,  saw  the  patella  through  in   the 
line  of  the  incision,  remove  the  fragments,  after  which        \       f\ 
the  joint  surfaces  are  exposed  and  removed  as  in  the  /   \ 

preceding   operations.       This    incision    affords   good  < 

drainage,  and  exposes  the  joint  by  a  minimum  injury  !     j  j 

of  the  soft  parts.  In  all  instances  the  diseased  syno-  j  j  .' / 
vial  membrane  should  be  carefully  dissected  away  be-  <  i  I  • 
fore  the  wound  is  closed.  In  all  forms  of  excision 
of  this  joint  care  must  be  taken  to  prevent  the  soft  "  '  incision. 
parts  posterior  to  the  bones  from  being  caught  be- 
tween their  sawn  surfaces,  since  this  will  hinder  union  by  preventing 
a  proper  contact  of  their  surfaces.  If  the  two  wire  sutures  be  carried 
through  to  the  posterior  borders  of  the  bones,  this  accident  can  not 
occur.  If  the  patella  be  permitted  to  remain,  its  severed  ligament 
may  be  united  by  suturing,  or,  if  the  bone  have  been  sawn  across,  the 
bony  fragments  may  be  united  by  strong  catgut  or  silver  wire.  It  is 
thought,  in  cases  of  imperfect  union  of  the  tibia  and  femur,  that  the 
presence  of  the  patella  gives  greater  stability  to  the  limb. 

Excision  of  the  Patella. — It  may  be  necessary,  on  account  of  ne- 
crosis or  injury,  to  remove  the  patella  independently  of  the  tibia  and 
femur.  In  such  cases  the  deep  incisions  must  correspond  in  extent  to 
the  diseased  bone,  for  if  they  be  greater,  the  synovial  cavity  may  be 
opened.  The  periosteum  should  be  raised,  and  the  dead  bone  care- 
fully removed,  if  possible,  without  entering  the  joint.  When  the  joint 
is  not  involved,  recovery  will  be  speedy  and  satisfactory,  if  the  limb 
be  confined  in  the  extended  position  till  sufficient  repair  has  taken 
place  to  warrant  flexion  without  fracture  of  the  bone. 

The  results  in  eleven  cases  are  two  deaths  and  nine  recoveries,  of 
which  eight  were  complete  and  three  partial  excisions. 

Excision  of  the  Great  Trochanter. — This  is  occasionally  required  on 
account  at  caries.  A  Longitudinal  or  curved  incision  is  made  down 
upon  the  bone,  and  the  diseased  portion  removed  with  the  usual  in- 
struments.    The  branches  <>f  the  circumflex  and  the  capsular 


208  OPERATIVE   SURGERY. 

ligament  are  to  be  avoided.  The  periosteum  should  be  saved  when 
possible. 

Excisions  of  the  Hip-Joint.— It  is  well  before  attempting  this  opera- 
tion to  give  a  brief  survey  of  the  important  ligamentous  and  muscular 
attachments  to  be  respected.  The  extent  of  this  book  is  too  limited 
to  describe  them  in  detail,  and  even  to  do  so  would  hardly  be  in  keep- 
ing with  the  scope  of  the  work. 

The  ilio-femoral,  capsular,  cotyloid,  and  even  the  teres  ligaments, 
should  be  carefully  considered  in  connection  with  their  origin  and  in- 
sertion, in  order  that  their  relations  to  the  involucrum  or  periosteum 
may  be  maintained.  Those  muscles  which  are  connected  with  the  tro- 
chanters major  and  minor  should  likewise  be  preserved  intact,  in 
order  that  their  association  with  the  new  bone-growth  may  give  to  the 
new  joint,  so  far  as  possible,  the  normal  functions  of  the  old. 

The  results  of  this  operation  are  substantially  as  follows  :  When  done 
for  gun-shot  injuries,  about  ninety-two  and  a  half  per  cent  die  from 
the  primary ;  about  ninety-one  per  cent  from  the  intermediary,  and 
ninety  and  a  half  from  the  secondary  operation.  When  done  for  dis- 
ease, the  mortality  is  reported  variously  from  thirteen  (Sayre)  to  forty- 
five  per  cent.  The  most  favorable  age  is  between  five  and  ten  years  ; 
the  best  results  are  said  to  occur  when  the  disease  has  existed  several 
months.  The  rate  is  about  three  per  cent  greater  from  complete  than 
partial  excisions.  The  rate  of  mortality  is  but  little  improved  by  the 
removal  of  the  trochanter  major,  and  the  upper  portion  of  the  shaft ; 
it  is  diminished,  however,  from  the  head  of  the  femur  downward,  in 
proportion  to  the  amount  of  diseased  bone  removed,  and  is  increased 
in  proportion  to  the  extent  of  the  disease  of  the  ilium.  About  ninety- 
four  per  cent  secure  useful  limbs,  when  excised  for  disease.  Complete 
excision  is  followed  by  a  more  useful  limb  than  partial  excision. 

The  hip-joint  may  be  removed  with  or  without  the  preservation  of 
the  periosteum,  by  two  quite  distinct  methods  of  operating :  1.  The 
simple,  when  no  effort  is  made  to  save  the  periosteum,  and  the  mus- 
cular and  ligamentous  attachments  about  the  joint  are  freely  sacri- 
ficed. This  method  is  applicable  for  malignant  disease  of  the  bone, 
and  for  injuries  causing  extensive  comminution  and  laceration.  2. 
The  conservative,  in  which  conscientious  care  will  often  be  repaid 
in  peeling  off  the  periosteal  tissue  and  muscular  attachments  worthy 
of  preservation.  Under  all  circumstances  the  acetabulum  should  be 
closely  scrutinized  for  the  presence  of  dead  bone,  which  should,  in  all 
instances,  be  removed  with  care,  otherwise  the  pelvic  contents  may  be 
injured  by  the  manipulation. 

Operation  (White). — The  simple  method  is  performed  by  placing 
the  patient  on  the  healthy  side,  and  making  a  deep  curved  incision 
(Fig.  283),  commencing  at  a  point  midway  between  the  anterior  supe- 
rior spinous  process  of  the  ilium  and  the  trochanter  major,  and  pass- 


OPERATIONS   OX   BOXES. 


209 


ing  backward  around  the  top  of  the  trochanter  major,  down  its  pos- 
terior border  about  three  or  four  inches,  with  a  strong  knife  ;  then 
dividing  the  insertions  of  the  muscles  connected  to  the  great  trochan- 
ter (Fig.  284),  drawing  them 
aside  with  a  spatula,  and  expos- 
ing the  posterior  surface  of  the 
neck  cf  the  femur  and  the  ace- 
tabulum. The  exposure  will  be 
still  more  complete  if  the  femur 
be  rotated  strongly  inward.  If 
the  cotyloid  and  capsular  liga- 
ments be  now  divided,  and  the 


Fig.  283. — White's  posterior  curved  in- 
cision. 


Fig.  284. — Sciatic  nerve  and  external 
rotator  muscles. 


thigh  be  flexed  and  adducted,  the  head  of  the  bone  will  be  raised 
from  the  acetabulum  sufficiently  to  admit  of  the  division  of  the  liga- 
mentum  teres,  when  the  complete  escape  of  the  head  of  the  femur  will 
take  place.  The  soft  parts  are  then  protected  by  a  spatula,  the  bone 
exposed  the  required  extent,  and  sawn  off  (Fig.  285). 

Subperiosteal  Excision  of  the  Hip-Joint  (Langenbeck). — Place  the 
patient  on  the  sound  side  with  the  thigh  flexed  at  an  angle  of  45°  ; 
make  an  incision  five  or  six  inches  in  length  in  the  long  axis  of  the 
greal  trochanter  (Fig.  286)  upward  and  backward  toward  the  posterior 
superior  spine  of  the  ilium,  through  the  libers  of  the  gluteus  maxi- 
mus,  fascia  lata,  and  periosteum  of  the  trochanter;  separate  the  sur- 
faces of  the  wound  with  retractors,  and  with  the  elevator  and  knife 
the  periosteum  and  the  attachments  oi  the  muscles  inserted  into 
the  trochanter  major  and  the  contiguous  surfaces,  being  careful  to 

14 


210 


OPERATIVE   SURGERY. 


Fig.  285. — Sawing  off  head  of  femur. 


preserve  their  connections  with  each  other  ;  next  make  a  longitudinal 
incision  along  the  neck  of  the  femur,  through  the  capsular  ligament 
and  the  periosteum.  The  •. , 
periosteum  of  the  neck  is  \  4 
then  separated  in  connec- 
tion with  the  attachments 
of  the  capsular  ligament 
and  the  obturator  externus 
in  a  careful  manner.  If  an 
incision  be  now  made 
through  the  cotyloid  liga- 
ment, and  the  thigh  be  ro- 
tated outward  and  ad- 
ducted,  the  head  of  the 
bone  will  be  elevated  from 
the  floor  of  the  acetabulum 
sufficiently  to  admit  of  the 
division  of  the  ligamentum 
teres,  when  the  head  of  the 
bone  can  be  pushed  through 
the  opening  and  sawn 
off*  Fig.  286. — Langcnbcck's  longitudinal  incision. 


OPERATIONS   ON   BONES. 


211 


Sayre's  Operation. — The  following  admirable  method  of  excision  is 
recommended  by  Professor  Lewis  A.  Sayre.  It  is  subperiosteal  in  all 
essential  particulars,  and  possesses  an  advantage  over  the  one  just  de- 
scribed in  that  the  primary  incision  is  better  fitted  for  drainage.     Place 

the  patient  on  the  sound  side  and  make  an 
incision  with  a  strong  knife  down  to  the 
bone,  commencing  at  a  point  midway  be- 
tween the  anterior  superior  spinous  pro- 
cess of  the  ilium  and  top  of  the  trochanter 
major  ;  carry  it  in  a  curved  course  upon 
the  bone  to  the  top  of  the  great  trochanter 
midway  between  its  posterior  border  and 
center  ;  complete  it  by  carrying  the 
knife  forward  and  inward,  making  the 
length  of  the  incision  from  four  to  six  or 
eight  inches,  depending  upon  the  size  of 
the  thigh  (Fig.  287).  Jf  it  be  not  cer- 
tain that  the  periosteum  of  the  trochan- 
ter has  been  divided  by  the  first  incis- 
ion, the  knife  should  be  carried  along 
the  same  line  a  second,  and  even  a  third 
time  if  need  be.  The  soft  parts  are  now 
drawn  apart,  exposing  the  great  tro- 
chanter, when,  with  a  narrow,  thick 
knife,  a  second  incision  is  made  through  the  periosteum  only,  at  right 
angles  with  the  first,  about  an  inch  or  an  inch  and  a  half  from  the  top 
of  the  trochanter.  At  the  junction  of  the  periosteal  incisions  introduce 
the  blade  of  the  elevator,  and  carefully  peel  the  periosteum  from  either 
side  as  far  as  possible,  together  with  the  ligamentous  attachments,  un- 
til the  digital  fossa  is  reached.  The  insertions  of  the  rotators  into  the 
trochanter  major  and  digital  fossa  are  so  firm  that  it  will  be  impossible 
to  peel  them  off  ;  they  must,  therefore,  be  carefully  separated  by  short 
parallel  cuts,  so  directed  as  to  remove  the  periosteum  with  which  they 
are  blended.  After  the  separation  of  the  tendinous  insertions,  con- 
tinue to  elevate  the  periosteum  upon  either  side  of  the  neck,  using 
great  care  not  to  rupture  it.  Its  integrity  is  important  to  prevent  in- 
filtration into  the  surrounding  tissues,  provide  attachments  for  the 
important  ligaments  and  muscles,  also  as  the  basis  for  the  reproduc- 
lion  of  bone  which  it  is  hoped  will  take  place,  each  of  which  will 
exert  an  important  influence  in  the  preservation  of  a  useful  joint. 
Having  separated  the  periosteum  as  far  as  can  be  done  safely,  adduct 
the  thigh  carefully,  raise  the  head  of  the  bone  from  the  acetabulum, 
and  the  remaining  portion  can  be  detached.  Adduct  and  depress  the 
femur  slightly,  being  careful  no!  to  tear  the  periosteum,  lift  the  bead 
of  the  bone  out  far  enough  to  admit  of  a  division  just  above  the  tro- 


Fic. 


-Sayrc's  line  of  incision. 


212 


OPERATIVE   SURGERY. 


chanter  minor.  Care  should  be  taken  not  to  expose  a  greater  surface 
than  is  necessary,  since  necrosis  will  follow  and  hinder  recovery.  It  is 
better  to  remove  the  trochanter  major,  even  though  it  be  not  dis- 
eased, since  it  will  impede  the  escape  of  discharges,  and  is  not  essen- 
tial to  a  useful  limb  if  its  periosteal  covering  and  muscular  attach- 
ments have  been  preserved.  In  all  cases  after  the  operation,  the 
wound  should  be  well  irrigated  with  a  strong  solution  of  carbolic  acid, 
thoroughly  smeared  with  balsam  of  Peru,  and  loosely  filled  with  fine, 
well-shaken  oakum  ;  good  drainage  provided,  and  extension  applied 
to  the  limb  either  by  the  Buck's  apparatus  or  the  wire  breeches. 

Excision  of  the  Coccyx. — This  is  ofttimes  done,  though  sometimes 
ineffectually,  for  the  relief  of  coccydynia.  The  operation  exposes  the 
patient  to  no  danger,  and  can  but  remove  a  comparatively  useless 
appendage. 

Operation. — Place  the  patient  on  the  side  and  expose  the  bone  by 
a  straight  incision  in  the  middle  of  its  long  axis  ;  isolate  it  carefully 
and  remove  it  with  bone-forceps. 

OSTEOTOMY. 

In  a  liberal  acceptation,  osteotomy  may  be  defined  as  a  section  of 
bone. 

In  a  limited  sense,  however,  it  is  applied  to  the  divisions  of  bone 
that  may  be  made  for  the  relief  of  deformities  dependent  on  anchylosis, 
rickets,  badly  united  fractures,  etc.  It  may  be  performed  either  with 
or  without  antiseptics.     The  former,  however,  is  by  far  the  safer  plan. 

The  Instruments  employed  consist  of  especially  designed  saws, 
chisels,  osteotomes,  mallets,  scalpels  and  blunt  hooks,  and  sand-pil- 
lows. 

There  are  variously  formed  saws  employed,  named  usually  after 
the  one  who  desigued  them,  as  Langenbeck's  (Fig.  288)  and  Adams' 


Fig.  288. — Langenbeck's  saw- 


saws  (Fig.  289).  The  blades  are  short  and  strong ;  one  fourth  of  an 
inch  in  width  and  an  inch  and  a  half  in  length,  connected  to  the 
handle  by  a  strong  shank  three  inches  long.     The  deviations  from 


OPERATIONS   ON  BONES. 


213 


these  are  to  meet  especial  indications,  rather  than  to  abrogate  their 
use. 

The  objections  to  the  use  of  the  saw  not  only  apply  to  the  danger 


Fig.  289.— Adams'  saw, 


of  lacerating  the  contiguous  tissue,  but  more  forcibly  to  the  retention 
in  the  wound  of  the  bone-dust,  which,  failing  to  be  absorbed,  is  apt 
to  be  followed  by  suppuration.  The  saw  devised  by  Dr.  George  F. 
Shrady,  of  this  city,  is  the  best,  and  is  described  by  himself  as  follows  : 
Figs.  290  and  291.  "The  instrument  consists  of  a  trocar  (])  and 
a  staff  (2),  with  a  handle  and  blunt  extremity.     A  portion  of  this 


Fig.  290. — Shrady's  saw. 

shaft  at  a  short  distance  from  the  extremity  is  flattened,  one  edge  (B) 
being  made  into  a  knife-blade,  and  the  other  (C)  being  provided  with 
saw-teeth.  This  shaft  is  intended  to  replace  the  trocar  in  the  canula 
after  the  latter  is  introduced.  When  in  position  (3)  either  the  saw 
(C)  or  the  knife-edge  of  the  shaft,  according  to  the  way  the  latter  is 
turned,   corresponds  with  the  opening  of  the  canula.     The  saw  or 


^*^a*xb 


CSJWELl  HMftP.r, 

w.r.nno . 


Vi ..  291.— Shrady's  modified  saw. 


214  OPERATIVE   SURGERY. 

knife  can  then  be  worked  to  and  fro  within  the  canula  by  a  piston- 
like movement,  the  canula  being  steadied  by  grasping  the  flange  (D) 
at  its  base.  If  it  be  necessary  to  work  the  instrument  as  an  ordinary 
blunt-pointed  sheathed  saw  or  knife,  the  shaft  can  be  fixed  in  the 
canula,  and  made  into  one  piece  by  a  thumb-screw  in  the  handle. 
The  portion  of  the  canula  at  the  back  of  the  opening  is  made  extra 
strong,  and  is  of  the  same  thickness  as  the  blade,  so  that  in  sawing 
there  is  no  stoppage  of  the  passage  of  the  instrument  through  any 
thickness  of  the  bone.  The  soft  parts  are  protected  from  injury,  no 
matter  which  way  the  instrument  may  be  worked.  The  saw-blade  is 
blunt  at  its  extremity,  and  is  guarded  on  all  sides  except  in  its  limited 
cutting  surface.  The  same  may  be  said  of  the  knife.  The  working 
of  the  saw  to  and  fro  in  the  canula  is  sufficient  in  sweep  to  insure  the 
division  of  any  bone  having  a  diameter  less  than  the  cutting  edge. 
Still,  as  this  process  is  much  slower  than  when  the  saw  is  used  in  the 
ordinary  way,  it  is  perhaps  better  to  restrict  its  employment  to  opera- 
tions on  the  smaller  bones,  to  cramped  localities,  and  to  situations 
where  there  is  special  danger  of  wounding  some  neighboring  vessels. 
All  that  is  necessary  in  using  this  saw  is  to  thrust  the  trocar  and 
canula  into  the  limb,  the  fenestrum  of  the  canula  being  alongside  of 
the  bone  upon  which  the  operation  is  to  be  performed.  The  trocar  is 
then  withdrawn,  the  staff  introduced  in  its  place,  and  worked  as 
already  described." 

Since  the  above  description  was  written,  the  instrument  has  been 
slightly  modified  by  lessening  the  size  of  the  fenestrum  through  which 
the  teeth  of  the  saw  are  seen  ;  this  strengthens  the  canula  and  facili- 
tates its  progress  through  the  bone  (Fig.  291). 

Tfie  Chisel  is  like  that  of  the  carpenter  in  form,  but  differs  from 
it  in  temper  ;  it  has  two  parallel  sides  extending  to  its  cutting  edge. 
The  cutting  surface  has  one  side  straight  and  the  other  beveled,  and 
should  be  one  eighth  of  an  inch  thick  at  the  base  of  the  bevel  ;  if 
thicker,  it  may  splinter  the  bone.  The  breadth  varies  according  to 
the  size  of  the  bone  ;  half  an  inch  is  suitable  in  the  majority  of  cases. 
For  narrow  bones  one  fourth  inch  is  better  (Fig.  292).  The  width 
should  always  be  less  than  the  bone  to  be  operated  upon. 

The  temper  given  to  the  tools  of  the  hard-wood  or  ivory  turner  is 
best  suited  for  the  purpose,  and  its  efficacy  should  be  tested  upon  the 
thigh-bone  of  an  ox  or  like  animal  before  using  the  instrument. 

The  chisel  should  be  sharp,  and  leave  a  smoothly  cut  surface.  This 
instrument  is  employed  only  to  remove  a  wedge-shaped  piece  from  the 
bone,  since  the  shape  of  its  cutting  extremity  will,  like  that  of  the 
carpenter's  chisel,  cause  it  to  go  awry  if  a  straight  section  be  at- 
tempted. 

The  Osteotome.—  This  instrument  is  beveled  on  both  edges,  resem- 
bling a  slender  wedge ;  the  handle  and  the  blade  forming  one  piece. 


OPERATIONS   ON   BONES. 


215 


Fio.  292. — Chisels  and  osteotomes. 


The  top  should  have  a  round  head,  against  which  the  thumb  is  pressed 
to  steady  it.  One  border  of  the  blade  should  be  delicately  marked  in 
inches  to  determine  the  depth  of  the  incision.  The  edge  should  be 
sharp  enough  to  cut  the  finger-nails,  and  the  temper  of  a  character  to 
withstand  the  strain  required.  It  can  be  tested  upon  the  thigh-bone 
of  the  ox,  when,  if  it  neither  turn  nor  chip,  it  is  calculated  to  with- 
stand the  test  of  human  bone.  Osteotomes  vary  in  thickness,  in  order 
that  a  section  begun  by  one  of  a  given  thickness  may  be  continued  on 
its  withdrawal,  by  the  substitution  of  another  of  a  less  thickness. 

Tlie  Mallet  is  made  of  hard  wood,  and  can  be  constructed  for  the 
purpose  ;  or,  an  extemporized  one  may  be  employed. 

The  Scalpel  is  an  ordinary  one,  with  a  sharp  point  suitable  for 
penetrating  at  once  to  the  bone.  Blunt  hooks  are  employed  to  draw 
the  edges  of  the  incision  apart  without  force. 

The  Sand-Pillow.  —  Its  dimensions  are  usually  about  eighteen 
inches  by  twelve  ;  made  of  stout  cloth,  and  filled  with  sufficient  fine 
sand  to  permit  its  contents  being  moved  from  one  part  of  the  bag  to 
another,  without  leaving  any  portion  empty.  It  should  be  dampened 
before  being  used,  covered  with  carbolized  cloth,  and  the  limb  laid 
upon,  or  rather  imbedded  in  it.  It  forms  an  efficient  support,  and 
prevents  the  force  imparted  to  the  bone  by  the  mallet  injuring  the 
soft  parts. 

The  opening  through  the  soft  parts  leading  down  to  the  point  of 
proposed  section  should  be  limited  in  extent,  and  so  located  as  to 
avoid  the  division  of  veSfl  lis,  or  injury  to  a  joint.  It  should  be  made 
when  practicable  in  the  long  axis  of  the  fibers  of  the  muscle  through 
which  it  passes  down  to.  hut  not  through,  the  periosteum.  The  blade 
of  the  scalpel  should  remain  in  the  incision  till  the  danger  of  muscu- 
lar contraction  ceases,  and  then  the  chisel  or  o-teotome  is  passed  into 


216 


OPERATIVES   SURGERY. 


the  incision  by  the  side  of  it,  as  a  guide,  after  which  the  blade  can 
be  withdrawn. 

It  is  better  that  the  wound  be  large  enough  to  admit  the  finger,  or 
even  to  permit  inspection  of  the  bone,  than  that  the  tissues  around  a 
small  incision  be  treated  with  violence,  in  the  effort  to  accomplish  the 
purpose. 

If  chips  of  bone  are  to  be  removed,  a  larger  incision  is  required 
than  if  a  simple  section  be  intended.  The  patient  should  in  all  in- 
stances be  anaesthetized  and  the  limb  rendered  bloodless  by  the  elastic 
bandage  of  Esmarch  or  Martin.  All  cutting  instruments  employed 
must  be  rendered  aseptic,  and  in  all  other  respects  the  operation  must 
be  performed  with  antiseptic  care. 

Subcutaneous  Division  of  the  Neck  of  the  Femur  (Adams). — Place 
the  patient  upon  the  side,  with  the  bone  to  be  operated  upon  upper- 
most. Introduce  a  long  slender  scalpel  or  tenotome  above  the  top  of 
the  great  trochanter,  straight  down  to  the  neck  of  the  femur  ;  divide 
the  muscles  and  open  the  capsule  freely  on  the  anterior  and  upper  sur- 
face ;  pass  the  small  saw  by  the  side  of  the  knife  along  the  track  down 
to  the  anterior  surface  of  the  neck,  which  is  then  sawed  transversely 
through  (Fig.  293)  from  before  backward  suf- 
ficiently to  be  easily  broken.  The  limb  is  then 
placed  in  position,  the  wound  irrigated  with 
an  antiseptic  solution,  to  render  it  aseptic  and 
to  wash  out  the  bone-dust  ;  hemorrhage  is 
checked,  a  small  drainage-tube  introduced,  the 
remaining  portion  of  the  incision  closed,  the 
whole  enveloped  in  antiseptic  dressing,  and 
the  limb  placed  in  an  immovable  apparatus. 
The  tendinous  contractions,  that  prevent  the 
limb  being  placed  properly,  should  be  divided 
subcutaneously. 

Results. — This  operation  has  been  success- 
ful in  thirty-one  out  of  thirty-four  cases. 

Maunder,  Billroth,  and  others  have  used 
the  chisel  for  forcible  fracture  with  good  re- 
Another  method  (Volkmann)  consists  in  forming  a  false  joint 
in  the  following  manner  : 

Make  an  incision  along  the  posterior  surface  of  the  great  trochan- 
ter four  or  five  lines  in  length  down  to  the  bone.  The  femur  is  then 
cut  through  about  an  inch  below  the  point  of  the  great  trochanter, 
with  a  chisel,  the  wall  of  the  cervix  femoris  broken,  and  this  portion 
of  the  bone  removed.  The  thigh  is  then  adducted  to  make  the  upper 
end  of  the  femur  more  accessible  then  it  is  cut  across  and  rounded 
off  to  fit  the  new  socket  which  is  made  by  chiseling  out  the  head  of 
the  femur  and  increasing  the  area  of  the  acetabulum  by  the  same 


Fig. 


suits. 


293. — Sawing  neck 
of  femur. 


OPERATIONS   ON   BONES. 


217 


process,  being  careful  not  to  open  into  the  pelvic  cavity.  The  upper 
end  of  the  femur  is  placed  in  the  newly-formed  cavity,  and  extension 
is  applied  to  the  limb  to  keep  the  cut  surfaces  sufficiently  separated 
to  prevent  bony  union.  Early  passive  motion  should  be  made.  Volk- 
mann  has  performed  this  operation  several  times,  resulting  in  useful 
limbs  in  each  instance. 

Inter-trocliantcric  Osteotomy. — This  operation  consists  in  exposing 
the  anterior,  outer,  and  posterior  surfaces  of  the  femur  through  an  in- 
cision about  six  inches  in  length,  beginning  just  above  the  tip  of  the 
trochanter  major,  and  carried  longitudinally  through  the  center  of  its 
outer  surface.  A  short,  transverse  incision  is  then  joined  to  the  cen- 
ter of  the  posterior  lip  of  the  first ;  the  respective  surfaces  are  then 
exposed  with  an  elevator  until  the  trochanter  minor  can  be  felt,  when 
a  chain-saw  is  passed  around  the  bone  immedi- 
ately above  this  process.  The  uppermost  or 
curved  section  (Fig.  294)  is  made  by  first  saw- 
ing upward  and  outward,  until  the  bone  is 
half  severed,  then  changing  the  direction 
downward  and  outward  and  completing  the 
section. 

The  second  section  is  made  by  sawing  direct- 
ly through  the  bone  in  its  transverse  axis,  re- 
moving a  piece  one  eighth  of  an  inch  thick  at 
its  outer  and  posterior  border,  and  three 
fourths  of  an  inch  of  its  central  part. 

The  upper  end  of  the  lower  fragment  is 
then  rounded  to  fit  the  concavity  above.  The 
limb  is  straightened  out  and  the  wound  treated 
like  a  compound  fracture. 

This  method  was  practiced  by  Professor  L.  A.  Sayre  some  time 
since  with  eminent  success. 

The  removal  of  a  disk  of  bone  in  this  situation  has  been  quite  fre- 
quently done,  but  with  indifferent  success.  Out  of  the  seventeen 
cases  reported,  seven  died.  While  this  method  displayed  great  ingenu- 
ity and  resource  on  the  part  of  the  originator,  the  fatality  attending 
it,  together  with  the  introduction  of  the  chisel  and  osteotome,  render 
it  at  the  present  time  impracticable. 

The  modification  introduced  by  Volkmann  in  1873  consists  in 
making  an  incision  along  the  posterior  surface  of  the  great  trochanter 
and  removing  the  periosteum  from  two  thirds  of  its  circumference, 
when  with  chisels  and  gouges  a  triangular  piece  is  taken  from  just 
below  the  trochanter  (Fig.  205),  the  bone  broken,  straightened,  and 
placed  in  proper  position  until  union  takes  place. 

//<  nil,-.  —Of  the  twelve  operations  thus  performed,  ;ill  recovered. 

Osteotomy  for  Eony  Anchylosis  of  Knee-Join':  (supra-condyloid). — 


Fig.  294. — Sayrc's  lines 
of  section. 


218 


OPERATIVE   SURGERY. 


Fig.  295. — Volkmann's 
section. 


Make  a  longitudinal  incision,  sufficient  to  admit  the  osteotome,  at  the 
outer  side  of  the  rectus  tendon,  one  finger's  breadth  above  the  upper 
portion  of  the  outer  condyle.  The  osteotome  is 
introduced,  and  turned  so  that  its  cutting  sur- 
face corresponds  to  the  transverse  axis  of  the 
bone  at  the  point  to  be  divided  ;  with  the  limb 
resting  upon  the  sand-bag,  the  bone  is  two 
thirds  divided  and  the  remainder  broken  or 
beot.  If  performed  from  the  inner  aspect,  the 
incision  is  made  along  the  anterior  border  and 
half  an  inch  in  front  of  the  tendon  of  the  ad- 
ductor magnus,  beginning  one  inch  above  its 
insertion.  The  remaining  steps  of  the  opera- 
tion are  similar  to  the  preceding.  It  may  be 
necessary  to  supplement  the  section  of  the  fe- 
mur with  that  of  the  tibia,  in  order  to  suffi- 
ciently correct  the  deformity.  This  is  done  by 
making  an  incision  through  the  skin  over  the 
tibial  crest  just  below  the  tuberosity.  Through 
this  opening,  the  subcutaneous  and  posterior  surfaces  of  the  tibia  are 
divided  sufficiently  to  admit  of  a  fracture  of  the  bone  and  the  conse- 
quent correction  of  the 
deformity.  The  fibula, 
owing  to  its  mobile  asso- 
ciation with  the  tibia, 
does  not  require  division 
at  this  situation.  It  is 
often  necescary,  how- 
ever, to  cut  the  ham- 
string tendons  before 
the  deformity  can  be 
properly  corrected. 

Supra  -  Condyloid 
Osteotomy  for  Genu  Val- 
gum (Macewen)  (Fig. 
296). — In  this  operation 
care  is  taken  to  avoid 
the  popliteal  vessels, 
anastomotica  magna, 
superior  internal  articu- 
lar arteries,  and  the  syn- 
ovial pouch  of  the  knee- 
joint  on  the  anterior  surface  of  the  femur.  The  incision  in  the  soft 
parts  is  made  at  the  inner  side  of  the  limb,  beginning  a  finger's 
breadth  above  the  insertion  of  the  tendon  of  the  adductor  magnus  into 


Fig.  296. — Genu  valgum. 


OPERATIONS   ON   BOXES. 


219 


the  spine  at  the  upper  portion  of  the  internal  condyle  and  half  an 
inch  in  front  of  it,  and  carrying  it  up  sufficiently  to  admit  the  osteo- 
tome ;  or,  its  lowest  limit  is  made  to  correspond  to  a  line  drawn  trans- 
versely across  the  limb  in  front,  beginning  an  inch  above  the  external 
condyle,  which  will,  if  the  internal  condyle  be  much  elongated,  pre- 
vent the  osteotome  being  driven  into  the  exter- 
nal condyle,  instead  of  above  it.  The  course 
of  this  incision  avoids  as  far  as  possible  any  in- 
terference with  the  anastomotica  magna  and 
the  articular  arterial  branches.  The  osteotome 
may  be  applied  to  the  bone  transversely  at  the 
point  indicated  by  the  faint  transverse  undotted 
line  in  Fig.  297,  and  so  directed  that  its  course 
will  correspond  to  a  line  extending  across  the 
posterior  surface  of  the  femur  to  a  point  one 
finger's  breadth  above  the  external  condyle. 
The  extent  of  the  osseous  incision  will  depend 
upon  the  density  of  the  bone  ;  if  the  subject 
be  young,  and  if  the  bone  be  cut  through  two 
thirds  of  its  diameter,  it  can  be  bent  or  broken. 
If  it  be  dense,  it  will  be  necessary  to  carry  the 

incision  to  the  outer  wall.     The  posterior  and  inner  surfaces  of  the 
bone  are  first  cut,  when,  if  necessary,  a  thinner  chisel  is  employed  to 


Fig.  297. — Line  of  bone 
section. 


Fig.  298.  Fig.  299.  Fig.  300. 

FlGS.  29S,  299,  800, — Macewen's  method. 


Fig.  301.  Fig.  302. 

Figs.  301,  302.— Cgsten's  method. 


complete  the  operation.  When  the  bone  is  sufficiently  divided,  the 
limb  is  straightened,  all  hemorrhage  arrested,  and  the  limb  treated 
as  before  indicated.  The  above  figures  will  aid  in  explaining  the 
method. 

Fig.  298  -how-'  a  long  internal  condyle  in   genu  valgum  ;    Fig.  299, 

a  -<)ion  through  aboui  three  fifths  of  its  diameter ;  Fig-  300,  the  ap- 
pearance of  the  bone   with   the   limb  placed  in  position,  showing  tin: 


220  OPERATIVE  SURGERY. 

curvature  rectified.  The  prognosis  of  this  operation,  with  reference 
to  usefulness  of  the  limb,  cure  of  the  deformity,  and  danger  to  life, 
is  most  flattering. 

Results.— In  about  six  hundred  and  fifty  supra-condyloid  osteoto- 
mies, but  three  fatal  cases  are  reported  that  can  be  attributed  to  the 
operation ;  one  each  from  septicemia,  hemorrhage,  and  carbolic-acid 
poisoning.  All  the  patients  were  benefited,  and  many  were  able  to 
take  an  active  part  in  affairs  from  which  they  had  been  debarred. 

Osteo-Artlirotomy  (Ogsten).— This  method  consists  in  dividing  the 
elongated  condyle  of  the  femur  by  sawing  (Ogsten),  or  cutting 
(Reeves),  sufficiently  to  admit  of  the  rectification  of  the  deformity 
(Figs.  301,  302). 

Operation  by  Sawing. — Place  the  patient  in  the  dorsal  position  ; 
administer  an  anaesthetic  :  flex  the  leg  upon  the  thigh,  fully.  At  a 
point  two  or  three  inches  above  the  tip  of  the  inner  condyle,  introduce 
a  tenotome  upon  the  flat,  carry  it  downward,  forward,  and  outward 
until  its  point  can  be  felt  in  the  inter-condyloid  space.  The  cutting 
edge  is  then  turned  downward  and  the  tissues  divided  down  to  the 
bone  as  it  is  withdrawn.  A  small  Adams'  saw  is  then  introduced 
along  the  course  of  the  incision  and  the  condyle  is  sawn,  from  above 
downward,  through  about  three  fourths  of  its  thickness.  If  the  limb 
be  now  straightened,  the  remaining  portion  is  fractured  and  the  de- 
formity is  rectified. 

Results. — In  forty-six  operations  two  patients  have  died  of  septi- 
caemia. 

Operation  ly  Cutting. — By  this  method  the  elongated  condyle  is 
divided  or  loosened  with  a  chisel  or  osteotome  ;  the  intention  being  to 
divide  the  condyle  to  the  greatest  depth  without  opening  into  the 
joint.  Even  though  the  cut  be  made  to  meet  this  indication,  the 
joint  is  no  doubt  involved  (except  possibly  in  the  very  young)  by  the 
displacement  upward  of  the  fragment  necessary  to  correct  the  de- 
formity. 

Chiene's  Method. — Mr.  Chiene,  instead  of  sawing  or  cutting  off  the 
condyle,  corrected  the  deformity  by  the  removal  of  an  oblique  trans- 
verse wedge  of  bone  from  the  body  of  the  condyle  which,  when  pressed 
upward  by  straightening  the  limb,  remained  attached  by  its  apex  to 
the  shaft.  Not  infrequently,  however,  the  fragment  is  detached  by 
this  manipulation,  and  the  joint  opened  into.  The  details  attending 
this  method  are  omitted,  since  it  can  not  be  compared  favorably  with 
the  much  simpler  and  equally  efficient  one,  supra-condyloid  osteotomy. 

Osteotomy  for  Genu  Varum.— In  this  deformity  the  operative  pro- 
ceedings are  directed  to  the  outer  instead  of  the  inner  side  of  the 
bones  of  the  leg  and  thigh.  The  procedure,  precautions,  and  treat- 
ment are  similar.  The  division  of  the  bones  through  a  small  external 
opening  can  be  made  almost  indiscriminately  in  such  as  present  this 


OPERATIONS   ON   BONES.  221 

deformity,  always  remembering  that  thorough  and  complete  antiseptic 
precautions  should  be  taken.  The  results  are  most  flattering,  and 
commend  it  to  the  consideration  and  practice  of  the  profession. 

Bow-Legs. — Genu  varum  may  depend  on  an  outward  curvature  of 
the  bones  of  the  leg,  wholly  or  in  part.  In  either  instance  the  de- 
formity can  be  corrected  by  a  subcutaneous  osteotomy  of  the  tibia. 
If  the  patient  be  young  enough,  a  green-stick  fracture  of  the  fibula 
will  obviate  the  use  of  the  osteotome  upon  it. 

Operation. — Cleanse  the  part  thoroughly  with  soap  and  brush  ; 
apply  the  elastic  bandage  ;  place  the  limb  on  the  sand-bag,  and  at  the 
point  of  the  greatest  curvature  make  a  longitudinal  incision  down  to 
the  periosteum,  midway  between  the  borders  of  the  subcutaneous 
bone  at  the  point  of  proposed  division,  of  ample  length  to  admit  the 
osteotome,  which  is  then  turned  so  as  to  divide  the  bone  transversely, 
sufficiently  to  admit  of  its  being  fractured.  Cut  or  bend  the  fibula, 
correct  the  deformity,  close  the  wound  in  the  soft  parts  with  catgut, 
dress  antisepticaily,  and  confine  the  limb  in  a  temporary  dressing 
until  all  danger  of  hemorrhage,  inflammation,  etc.,  has  subsided, 
when  it  may  be  placed  in  an  immovable  plaster-of-Paris  dressing,  and 
retained  until  union  has  taken  place.  If  a  double  section  is  to  be 
made  at  different  points,  an  antiseptic  sponge  should  be  bound  over 
the  incision  in  the  soft  parts  of  the  first  while  the  second  operation  is 
being  made.  This  affords  an  opportunity  to  determine  the  severity  of 
the  hemorrhage  and  the  ease  with  which  it  can  be  controlled.  If  it 
be  necessary  to  divide  one  bone  in  two  situations  to  correct  a  deform- 
ity, the  second  division  should  be  deferred  until  the  former  has  healed, 
when  it  should  be  done  at  the  remaining  point  of  greatest  convexity. 
If  the  bones  be  much  curved,  it  may  become  necessary,  in  order  that 
the  deformity  be  properly  corrected,  to  remove  a  wedge-shaped  piece 
(cuneifom  ostreotomy).  For  this  purpose  the  chisel  alone  should  be 
employed.  In  all  instances  when  the  bichloride  gauze  is  to  be  applied, 
the  skin  must  be  protected  from  its  irritant  effects  by  smearing  it 
with  a  mixture  of  glycerin  and  salicylic  acid,  or  by  placing  between 
the  bichloride  gauze  and  the  skin  one  or  two  thicknesses  of  carbolic- 
acid  gauze  ;  the  latter  plan  is  the  better. 

All  osteotomies  should  be  performed  under  strict  antiseptic  precau- 
tion-, and  the  incision  of  the  soft  parts  closed  with  a  catgut  suture. 
The  limb  must  be  immovably  fixed  and  the  patient  kept  quiet ;  in 
fact,  the  measures  applicable  to  a  compound  fracture  are  in  order, 
since  it  resembles  that  condition  more  nearly  than  any  other. 

//.  ,///,-. — The  results  of  all  osteotomies  performed  with  antiseptic 
precautions  are  extremely  flattering.  As  yet,  I  have  no  personal 
knowledge  of  a  death  from  the  operation,  and  oi  fourteen  hundred 
osteotomies  hut  ahoui  one  per  cent  are  reported  to  have  died  in  con- 
sequence of  it. 


222  OrERATIVE   SURGERY. 

Hallux  Valgus.— This  deformity  is  practically  limited  to  the  great 
toe,  and  is  usually  caused  by  improperly  fitted  boots  and  shoes.  Fig. 
468  represents  the  condition  more  graphically  than  words  can  do  it. 
The  first  phalanx  (anatomical)  articulates  with  the  inner  portion  of 
the  distal  extremity  of  its  metatarsal  bone  and  is  rotated  inward  on 
its  long  axis.  The  principal  portion  of  the  head  of  the  metatarsal 
bone  projects  inward,  and  its  extremity  is  surrounded  by  a  sensitive 
bunion.  The  indication  is  to  place  the  toe  in  its  normal  axis  and 
retain  it  in  that  position.  If  the  deformity  be  great,  little  else  than 
an  operation  on  the  bone  will  be  of  any  practical  value.  Two  methods 
can  be  recommended  : 

1.  The  removal  of  the  head  of  the  metatarsal  bone,  with  enough 
of  the  shaft  to  permit  the  great  toe  to  be  easily  returned  and  held  in 
its  normal  axis  (Fig.  270).  Under  strict  antiseptic  precautions  this 
operation  results  in  quick  recoveries  and  useful  toes. 

2.  The  deformity  can  be  corrected  by  removing  a  V-shaped  piece 
from  the  inner  portion  of  the  distal  extremity  of  the  metatarsal  bone, 
as  near  the  head  as  possible  without  involving  the  joint  cavity.  This, 
too,  must  be  done  under  strict  antiseptic  precautions,  and  is  accom- 
plished through  an  incision  made  along  the  inner  side  of  the  meta- 
tarsal bone.  The  soft  parts  are  retracted  and  the  V-shaped  piece  of 
the  bone  is  removed,  without  dividing  more  than  three  fourths  its 
diameter.  The  thickness  of  the  base  of  the  triangular  piece  to  be 
removed  is  estimated  by  the  degree  of  the  deflection  of  the  toe  from 
its  normal  position  ;  it  should  correspond  as  nearly  as  practicable  to 
about  one  third  the  distance  which  the  extremity  of  the  toe  will  trav- 
erse to  regain  its  normal  relation  to  the  foot. 

The  wedge  can  be  removed  by  means  of  a  saw  or  chisel  and  the  toe 
brought  into  position,  which  will  fracture  the  inner  undivided  por- 
tions of  the  bone.  Horse-hair  drainage  and  immobility  under  anti- 
septic dressing  will  be  followed  by  speedy  union  and  a  satisfactory 
recovery. 

Osteoplasty,  or  transplantation  of  bone,  has  not  gained  the  promi- 
nence as  a  surgical  expedient  that  the  knowledge  of  the  laws  govern- 
ing the  growth  of  bone  bids  fair  to  attain  for  it. 

Bone  associated  with  its  periosteal  and  fibrous  connections,  has 
been  transferred,  as  in  the  case  of  the  operation  on  the  hard  palate  for 
the  closure  of  the  fissure,  also  the  closure  of  the  spaces  between  the 
ununited  fragments  of  bone,  by  filling  them  with  freshly  sawn  sections 
from  the  main  shaft.  The  conditions  necessary  to  a  successful  issue 
of  this  operation  are  exceedingly  numerous  and  exacting,  the  chief 
one  of  which  is  a  most  rigid  adherence  to  the  antiseptic  methods. 
The  feasibility  of  bone  transplantation  as  a  practical  measure  is  not, 
as  yet,  sufficiently  established  to  warrant  its  being  considered  an 
accomplished  fact. 


AMPUTATION'S.  223 

CHAPTER  IX. 

AMPUTATIONS.— GENERAL    CONSIDERA TION. 

Amputation-  consists  in  the  removal  of  a  limb  either  in  its  con- 

» 

tinuity  or  at  its  articulation,  although  the  latter  is  often  termed  dis- 
articulation. The  aims  sought  to  be  gained  by  an  amputation  are  :  1. 
The  saving  of  the  life  of  the  patient.  2.  The  securing  of  a  serviceable 
stump. 

If  the  prospects  of  recovery  be  annulled  by  the  presence  of  a  badly 
diseased  or  mangled  limb,  it  is  no  opprobrium  upon  the  art  to  remove 
it.  If  a  limb  be  so  badly  injured  or  diseased  as  to  require  removal,  it 
is  entirely  proper  that  the  ability  of  the  designer  of  compensative  ap- 
pliances be  considered,  that  the  patient  may  reap  the  combined  benefit 
of  the  art  of  the  surgeon  and  the  ingenuity  of  the  mechanic.  A 
stump,  to  be  serviceable,  should  be  sound,  unirritable,  with  a  good 
circulation  and  abundant  leverage.  The  first  three  qualities  depend, 
all  things  being  equal,  very  largely  upon  the  length,  shape,  and  vascu- 
lar supply  of  the  flaps ;  the  last  depends  entirely  upon  the  length  of 
the  bone.  The  flaps  should  be  movable  over  the  extremity  of  the 
stump  after  healing  is  completed,  not  tightly  drawn  and  smooth  like 
a  base-ball  cover.  Flaps  that  are  tightly  drawn  at  the  initial  dressing 
soon  become  more  so,  on  account  of  the  inflammatory  action.  The 
increased  tension  causes  pain,  and  early  and  rapid  ulceration  at  the 
seat  of  the  ligatures,  followed  by  separation  of  the  flaps,  union  by 
granulation,  and  finally  a  troublesome  stump  ;  or,  the  normal  shrink- 
age of  the  integument  draws  the  flaps  against  the  end  of  the  bone,  to 
which  they,  together  with  the  cicatrix,  become  immovably  united,  and 
cause  a  similar  difficulty.  The  proper  length  of  the  flaps,  then,  be- 
comes an  important  point  in  estimating  the  prospective  usefulness  of 
the  limb  and  comfort  of  the  patient.  In  cases  where  each  flap  can  be 
made  of  a  similar  length,  its  extent  should  correspond  to  about  one 
fourth  the  circumference  of  the  limb  at  the  point  where  the  bone  is  to 
be  divided.  If  one  flap  only  be  employed,  it  should  be  made  double 
the  length  of  each  flap  when  two  are  employed.  Any  increase  in  the 
length  of  one  flap  should  be  accompanied  by  a  proportionate  decrease 
in  the  length  of  the  other.  The  shape  of  the  flaps  largely  controls 
the  site  of  the  cicatrix.  It  is  advisable  that  the  cicatrix  be  so  placed 
as  not  to  be  subjected  to  pressure  or  friction.  If,  however,  the  flaps 
be  made  of  sufficient  length  to  admit  of  the  formation  of  a  non- 
adherent or  movable  cicatrix,  its  location  is  a  matter  of  secondary 
importance.  The  length  and  location  of  the  flaps  also  largely  control 
their  circulation.  If  they  be  too  long,  the  circulation  will  be  en- 
feebled ;  if,  on  the  contrary,  they  be  too  short,  the  tension  will  be- 
come an  impediment,  causing  a  blue,  cold,  and  shiny  surface,  sensitive 


224: 


OPERATIVE   SURGERY. 


to  the  slightest  injury.  The  circulation  in  the  normal  limb,  or  a  por- 
tion of  it,  may  be  such  as  to  predispose  to  a  small  and  sluggish  blood- 
supplv  in  flaps  constructed  from  it. 

Flaps  are  classified,  according  to  the  tissues  entering  into  them, 
as  the  cutaneous,  integumentary  or  skin  flaps,  musculo-cutaneous, 
and  periosteal,  either  variety  of  which  may  be  made  either  single  or 
double.  The  integumentary  variety  is  commonly  employed  in  this 
country. 

Flaps  are  also  classified,  according  to  their  shape,  into  circular, 
modified  circular,  oval,  rectangular,  hood,  etc.  The  oval  may  be 
either  unilateral,  bilateral,  anterior,  or  posterior.  Many  of  the  pre- 
ceding forms  may  be  composed  of  integument  alone,  or  combined  with 
muscular  tissue,  and  even  with  periosteum. 

Circular  Method  (Fig.  ,303).— This  method  is  followed  by  an  ad- 


Fig.  303. — Circular  method. 


mirable  stump,  is  easiest  of  performance,  and  consequently  very  fre- 
quently practiced.  It  is  especially  to  be  recommended  in  the  field 
operations  of  military  surgery,  since  the  lightness  of  the  flaps  permits 
the  transportation  of  the  wounded  with  the  minimum  degree  of  dis- 
turbance of  the  seat  of  the  amputation.  It  is  done  by  making  a  circu- 
lar incision  transversely  around  the  long  axis  of  the  limb,  through  the 
integument  and  subcutaneous  tissue  down  to  the  muscles,  at  a  distance 
below  the  proposed  division  of  the  bone,  corresponding  to  about  one 
fourth  the  circumference  of  the  limb  at  that  point.  The  flap  is  then 
dissected  up  from  the  muscles  with  an  ordinary  scalpel ;  the  edge  of 
the  knife  being  directed  toward  the  muscles  (Fig.  304)  rather  than 


AMPUTATIONS. 


225 


parallel  with  them  (Fig.  305),  as  the  latter  severs  the  capillary  con- 
nection between  the  integument  and  the  deeper  tissues.     The  dissec- 


Tig.  304. — Dissecting  up  the 


tion  should  be  done  by  circular  sweeps,  rather  than  by  mincing  cuts, 
which  hack  the  tissues  and  provoke  suppuration.     This  careful  man- 


Yic.  805. — How  not  to  do  it. 

ner  of  raising  the  flap  applies  equally  to  all  the  varieties  which  involve 
tli'-  separation  of  similar  tissues. 

If  the  limb  be  conical,  much  difficulty  will  be  experienced  in  turn- 
ing over  the  sleeve  of  integument ;  this,  however,  can  be  obviated  by 
a  longitudinal  cut  made  usually  at  the  most  dependent  portion  of  the 

flap. 

L5 


226 


OPERATIVE   SURGERY. 


The  flap  should  be  turned  upward  to  the  point  where  the  bone  is 
to  be  divided ;  then  with  suitable  knife  make  a  circular  division  of  the 


Fig.  306. — Circular  division  of  the  muscles. 


muscles  down  to  the  bone,  beginning  far  enough  below  the  reflection 
of  the  flap  to  allow  for  the  retraction  of  the  divided  muscles.  JSro 
definite  law  can  be  assigned  to  this  element, 
still  they  will  contract  according  to  their  size, 
length,  degree  of  irritability,  etc.  The  suita- 
ble points  of  section  will  be  stated  in  connection 
with  the  description  of  the  special  amputations. 
Not  infrequently  the  muscles  are  cut  just  below 
the  reflection  of  the  flap,  as  in  Fig.  306 ;  this 
is  not,  however,  as  good  a  plan  as  the  former, 
since  sensitive  stumps  are  more  liable  to  result 
therefrom.  The  bone  should  be  sawn  at  its 
highest  point  of  exposure. 

The  Modified  Circular  Method  (Fig.  308). 
— This  plan  was  suggested  by  Mr.  Liston,  who 
made  semilunar  flaps,  which  he  dissected  up  to 
their  point  of  junction  with  each  other,  at 
which  point  the  muscles  and  bone  were  divided, 
as  in  the  circular  method.  This  method  was 
afterward  modified  by  Mr.  Syme,  who  dissected 
a  short  distance  above  the  point  of  juncture  of 
the  flaps,  and  divided  the  muscles  and  bone,  as 
before.  In  either  instance,  however,  it  amounts  to  slitting  up  the  cuff 
of  a  circular  flap,  and  trimming  off  the  angles  caused  thereby. 


Fig.  307. — Stump  after 
the  circular  operation. 


AMPUTATIONS.  227 

The  Oval  Method. — This  is  in  reality  a  modified  circular  amputa- 
tion, the  flap  being  slit  up  at  one  side  and  the  angles  trimmed  off.     It 


Fig.  30S. — Modified  circular  flap. 

is  employed  principally  in  disarticulations,  and  will  be  described  in 
connection  with  those  operations. 

The  Single-Flap  Method. — This  is  adapted  to  those  cases  where 
the  tissues  of  one  side  of  the  limb  only  are  suitable  for  the  purposes 
of  a  flap  ;  as  in  the  case  of  lacerations,  ulcerations,  etc.  This  flap 
may  be  composed  of  the  muscular  tissues  and  integument,  or  of  in- 
tegument alone  ;  and  can  be  made  either  by  transfixion,  or  division 
from  without.  If  possible,  a  short  convex  flap  is  made  on  the  opposite 
surface  of  the  limb. 

The  Double-Flap  Operation  is  performed  by  transfixion,  and  includes 
the  muscles  down  to  the  bone  on  either  side  of  the  limb  (Figs.  309 
and  310).  The  tissues  to  be  transfixed  are  raised  slightly  by  the  left 
hand  of  the  operator,  who  then  enters  the  point  of  the  knife  at  the 
side  nearest  himself,  pushing  it  through  slowly,  in  close  contact  with 
the  anterior  surface  of  the  bone,  slightly  raising  the  handle  as  it 
passes  in  front  of  the  bone,  thereby  causing  its  point  to  emerge  at  the 
opposite  side  of  the  limb  at  a  point  exactly  opposite  to  its  entrance; 
the  flap  is  then  made  by  cutting  obliquely  upward  with  a  sawing  mo- 
tion. Jt  is  pulled  backward  by  an  assistant,  and  the  knife  is  reinsert- 
ed ;it  the  original  point  of  entrance,  carried  behind  the  bone,  handle 
depressed  to  cause  the  point  to  emerge  at  the  same  situation  as  at  the 
anterior  transfixion,  and  the  posterior  flap  made  by  cutting  obliquely 
downward.  Each  flap  should  correspond  in  length  to  at  least  one 
half  the  diameter  of  the  limb.     The  retractor  is  then  applied,  and  all 


228  OPERATIVE   SURGERY. 

the  soft  tissues  are  drawn  well  upward  ;  the  remaining  fibers  in  con- 
tact with  the  hone  are  severed  by  a  circular  sweep  of  the  knife,  and 


Fig.  309.  Fig.  310. 

Figs.  309,  310.— Flap  by  transfixion. 

the  bone  is  carefully  sawn  through.  If  lateral  flaps  be  made,  the  outer 
should  be  formed  first.  The  flap  containing  the  large  vessels  is  to  be 
divided  afterward. 

The  Mixed  Double  Flap  is  a  modification  of  the  preceding,  and 
sometimes  called  Sedillot's  method.  The  flaps  are  made  by  trans- 
fixion, as  before,  but  are  more  superficial,  the  knife  not  being  brought 
in  contact  with  the  bone.  The  remaining  muscles  and  vessels  are  di- 
vided by  a  circular  incision,  and  the  amputation  completed  as  before 
described.  In  this  instance  the  flaps  are  thinner  and  shorter  than  in 
the  preceding. 

LangenbecFs  Method. — This  differs  from  the  last  only  in  the  man- 
ner of  obtaining  the  result ;  the  flaps  being  cut  from  the  surface 
toward  the  center  of  the  limb,  which  affords  a  better  opportunity  to 
shape  them.  Another  modification  of  the  method  consist  in  cutting 
the  anterior  flap  from  the  surface,  and  making  the  posterior  flap  by 
transfixion. 

TJie  Rectangular  Flap,  or  TeaWs  Method  (Figs.  311  and  312). — 
In  this  two  rectangular  flaps  are  employed,  one  being  four  times  longer 
than  the  other ;  both  flaps  include  the  structures  down  to  the  bones. 
The  longer  flap  is  taken  from  the  side  of  the  limb,  where  the  bone  is 
most  superficial.  The  shorter  contains  the  important  vessels.  The 
length  and  breadth  of  the  long  flap  correspond  to  half  the  circumfer- 
ence of  the  limb  at  the  point  of  proposed  amputation.  The  width  of 
the  short  flap  is  a  half,  and  its  length  an  eighth,  of  the  circumference 
of  the  limb.     Both  flaps  should  be  carefully  marked  out  before  begin- 


AMPUTATIONS. 


229 


ning  the  operation.     This  method  makes  an  admirable  stump,  but 
sacrifices  fulcrumage,  and  brings  the  bone  section  nearer  the  body 


Fig.  311.  Fig.  312. 

Figs.  311,  312.— Tenle's  method. 


than  is  consistent  with  the  additional  dangers  incurred.  Mr.  Lister 
recommends  that  the  longer  flap  be  made  a  third  and  the  shorter  flap 
a  sixth  of  the  circumference  of  the  limb,  which  brings  the  cicatrix  at 
the  edge  of  the  stump.  Also  that  the  posterior  flap  shall  consist  of 
the  integument  and  subcutaneous  tissues  alone.  This,  like  Teale's, 
may  be  employed  when  the  loss  of  tissues  is  greater  upon  one  side 
than  upon  the  other. 

The  Hood  Flap. — There  is  no  substantial  difference  between  this 
and  the  circular  method,  if  the  latter  be  slit  up  at  the 
most  dependent  part,  and  the  resulting  corners  rounded 
off.     This  method  meets  the  indications  requisite  to 
form  a  good  stump  as  well  as  any  other  variety  of  flap. 

Equilateral  Flaps  (Fig.  313)  consist  of  equilateral 
skin-flaps,  oval  in  outline,  the  posterior  angle  being 
made  somewhat  farther  up  the  limb,  to  improve  the 
drainage.  The  muscles  are  cut  by  a  circular  sweep  at 
a  suitable  distance  below  the  point  of  reflection  of 
the  integumentary  flaps,  and  the  bone  is  sawn  above 
the  anterior  point  of  junction  of  the  flaps. 

Periosteal  Flap. — This  is  made  by  raising  the  pe- 
riosteum in  conjunction  with  the  tissues  which  rest 
upon,  or  are  attached  to  it,  sufficiently  to  cover  the 
end  of  the  divided  bones,  when  it  is  allowed  to  fall 
into  place.  It  is  best  adapted  to  those  bones  subcuta- 
neou-lv  located,  like  the  tibia,  and  will  be  again  re- 
ferred to  in  connection  with  amputations  of  the  leg. 

A   periosteal  flap  will,  if  it  becomes  adherent  to 
the  end  of  the  bone,  preserve   it   from  atrophy,  and 
the  danger  of  the  formation  of  a  conical  stump  ; 
it  likewise  prevents  the  adhesion  of  the  cicatrix  to  the  stump,  thereby 
forming  the  basis  for  a  movable  cicatrix. 


FlG.    :j.  13— Equi- 
lateral flaps. 


230  OPERATIVE   SURGERY. 

If  the  patient  be  young,  new  bone  may  be  developed ;  this  lessens 
the  sensibility  and  increases  the  usefulness  of  the  stump.  It  is  claimed 
by  some  that  the  bony  spiculse  often  shoot  into  the  soft  tissues  on  the 
end  of  the  stump,  and  require  a  second  operation  for  their  removal. 
It  is  my  opinion,  however,  that  if  the  periosteum  be  removed  entire 
and  in  connection  with  its  superimposed  tissues,  and  be  so  placed  that 
the  force  of  gravity  will  aid  in  holding  its  bone-producing  surface  in 
contact  with  the  divided  extremity,  this  danger  will  be  obviated. 

Comparative  Merits  of  Different  Forms  of  Flaps. — The  ends  sought 
to  be  gained  in  making  flaps  are  :  1.  To  secure  good  drainage.  2.  To 
make  them  of  suitable  length,  that  the  circulation  and  movement  of 
the  integumentary  cushion  at  the  end  may  be  unrestrained.  3.  To 
place  the  cicatrix  beyond  the  point  of  friction,  and  prevent  its  adhesion 
to  the  end  of  the  bone.  4.  To  guard  against  any  danger  of  undue 
sensibility,  by  making  the  flaps  of  proper  length,  and  by  drawing 
down  and  cutting  off  the  cutaneous  and  other  nerves  of  larger  size 
that  may  exist  in  them. 

With  these  aims  in  view,  it  will  be  seen  that  the  old-fashioned  cir- 
cular flap  affords  equal  advantages  to  the  others,  and  is  further  com- 
mendable for  its  simplicity.  It  is  true  that  in  this  method  the  scar 
will  fall  on  the  end  of  the  stump,  but  with  proper  precautions  as  to 
the  length  of  the  flaps  and  suitable  surgical  attentions,  any  danger 
from  this  source  is  reduced  to  a  minimum. 

The  Agents  required  for  an  Amputation  may  be  classed  as  those  for 
arresting  hemorrhage  ;  for  the  division  and  trimming  of  the  soft  parts 
and  the  bone  ;  and  those  for  uniting  and  dressing  the  wound.  The 
preparation  of  the  patient  for  the  operation  ;  the  agents  for  controlling 
and  arresting  hemorrhage,  together  with  the  various  methods  of  secur- 
ing and  maintaining  the  coaptation  of  the  cut  surfaces,  drainage,  and 
various  forms  of  dressing,  antiseptic  and  otherwise,  have  herein  been 
previously  considered ;  therefore,  there  remain  to  be  enumerated, 
under  this  heading,  only  those  instruments  especially  adapted  to  the 
requirements  of  the  operation. 

Amputating  Knives  (Fig.  314). — The  modern  amputating  knives 
can  be  used  for  making  circular  flaps,  or,  for  those  made  by  trans- 
fixion. They  should  be  double-edged  (catlin)  entirely  or  for  an  inch 
or  two  from  the  point.  The  length  of  the  knife  selected  will  depend 
upon  the  size  of  the  limb  to  be  operated  upon,  and  should  be  about 
one  and  a  half  times  its  diameter.  It  may  be  inconsistent  with  good 
taste,  but  it  is  entirely  consistent  with  good  judgment  and  economy, 
to  amputate  an  arm  or  forearm  with  the  knife  intended  for  the  thigh, 
and  the  result  will  be  equally  satisfactory. 

The  Manner  of  grasping  the  Amputating  Knife,  prior  to  and  during 
the  division  of  the  soft  parts,  adds  much  to  the  optical  effect  of  an 
operation.     It  should  be,  at  first,  lightly  grasped,  with  the  edge  for- 


AMPUTATIONS. 


231 


Fig.  314. — Amputating  knives. 

ward,  between  the  thumb  and  first  two  fingers,  near  enough  to  the  shank 
to  admit  the  upper  end  of  the  handle  to  play  between  the  heads  of  the 
metacarpal  bones  of  thumb  and  finger,  when  it 
is  swung  backward  and  forward  (Fig.  315). 
There  are  two  methods  employed  of  carrying 
it  entirely  around  the  limb  :  1.  Stand  with  the 
left  side  toward  the  patient,  seize  the  limb  above 
the  point  of  intended  operation  with  the  left 
hand,  an  assistant  holding  its  distal  extremity  ; 
place  the  left  foot  forward,  slightly  bend  the 
right  knee,  and  with  the  catlin  held  by  the  right 
hand,  as  before  described  (Fig.  315),  stoop 
downward  and  forward  sufficiently  to  carry  the 
knife  and  arm  under,  and  the  knife  over  the 
limb,  placing  its  heel  as  near  to  the  upper  sur- 
face of  the  limb  as  is  convenient,  when,  with  a 
sawing  motion,  it  is  drawn  toward  the  operator 
beneath  the  limb,  then  upward  between  it  and 
the  operator,  and  so  on  around,  until  it  joins 
the  beginning  of  the  cut,  making  a  complete 
circle  (Fig.  316).  If  the  knife  be  properly 
grasped,  it  will  pass  readily  between  the  thumb 
and  forefinger,  as  the  hand  passes  around  the  limb  ;  enabling  the  sur- 
geon to  make  the  section  with  perfect  ease,  and  without  the  least 
manifestation  of  stiffness.  2.  The  method  may  be  reversed  by  pass- 
ing the  hand  and  knife  over  instead  of  under  the  limb  (Fig.  317)  ; 
otherwise  the  manipulations  are  the  same.  The  latter,  however,  is 
less  natural,  besides  which  it  exposes  the  arm  of  the  operator,  and  the 
integument  to  be  divided  last,  to  the  flow  of  blood.  Still,  either  of 
these  methods  is  far  superior  to  the  one  commonly  employed  and  fig- 
ured in  text-books  (Fig.  318). 

The  Catlin  (Fig.  321). — This  is  chiefly  employed  to  divide  the  tis- 
sues in  the  interosseous  space,  in  amputations  of  the  leg  and  forearm. 
It  can  be  readily  supplemented  for  this  purpose  by  the  single-edged 
narrow  knife,  provided  the  latter  be  withdrawn  to  complete  the  divis- 


Fig.  315. — How  to  grasp 
the  amputating  knife. 


232 


OPERATIVE   SURGERY. 


Fig.  316. — How  to  carry  the  knife  around  the  limb. 


Fig.  3 11. — Another  method. 

ry  broad-bladed  saw  (Fig.  320) 
and  the  bow-backed  (Fig.  322) 
are  in  common  use.  The  first 
meets  all  requirements  except  in 
certain  excisions,  when  either  the 
chain-saw  (Fig.  239)  or  Butcher's 
saw  (Fig.  323)  must  be  employed. 
The  narrow,  movable-backed  saw 


ion  of  the  interosseous 
tissues, instead  of  chang- 
ing the  direction  of  the 
cutting  edge,  while  it 
remains  between  the 
bones.  The  latter  act 
will  bruise  and  tear  the 
interosseous  tissues. 

Two  or  three  ordina- 
ry scalpels  should  be 
added  for  raising  the  in- 
tegument, etc. 

A  knife  with  a  long, 
narrow  blade  is  the  bet- 
ter for  amputating  at 
the  phalangeal  articula- 
tions (Fig.  219). 

Saws. — The  ordina- 


A  common  method, 


AMPUTATIONS. 


233 


f'^y^, 


Fig.    319. —     Fig.  320. — Broad-bladed         Fig.  322. — Common  bow-saw. 
Metacarpal  saw. 

knife. 

(Fig.    241)   is  of  use  in  sawing  small  bones  and  removing 
Bpicnlae. 

The  Proper  Method  of  using  a  Saw  should  be  given  some 
attention  (Fig.   324).     After  the  division  of  the  soft  parts, 


Fig.    321. 
Catlin. 


^,vvv.v*v^*vvvvvvvvwvvvvvvWvw\^vv^vv\v^AVN^/^^^A*v\^^ 

Fio.  323. — Butcher's  bow-saw. 


234 


OPERATIVE   SURGERY. 


H 


the  bone. 


Fig.  326.— Fara- 
bcuf's  forceps. 

raises  it  from 


bleeding  points. 


Fig.  325. — Ferguson's  lion-jaw  for- 
ceps. 

the  surgeon  grasps  the  saw 
firmly,  places  its  heel  close 
to  the  border  of  the  re- 
tracted muscles,  in  a  line 
made  through  the  perios- 
teum by  the  knife,  and, 
while  guided  by  the  thumb- 
nail, slowly  and  carefully 
draws  it  toward  himself 
along  the  first  four  or  five 
inches  of  its  edge, 
the  track,  and  places  it  as  before ; 
repeating  the  operation  until  a  track 
of  sufficient  depth  is  made  to  re- 
tain it  during  the  to-and-fro  move- 
ments of  sawing,  which  should  be 
done  by  quick,  sharp  strokes,  until 
the  bone  is  nearly  severed,  when 
care  must  be  taken,  or  the  saw  will 
be  clamped  and  the  remaining  por- 
tion be  broken  off.  If  the  handle 
of  the  saw  be  raised  and  the  re- 
maining portion  be  divided  at  a 
different  angle  with  the  bone,  the 
danger  of  breaking  is  lessened. 
When  two  bones  are  to  be  sawed  off, 


AMPUTATIONS.  235 

the  saw  should  be  started  in  the  less  movable  bone,  and  then  turned 
so  as  to  include  both.  If  the  movable  one  clamp  the  saw,  cut  off 
the  more  solid  one  first,  then  complete  the  other.  The  proximal  and 
distal  portions  of  the  limb  should  be  supported  and  steadied  during 
the  sawing  of  the  bone. 

Bone-Forceps. — Liston's  cutting  forceps  (Fig.  227)  are  used  for 
trimming  off  rough  prominences.  Ferguson's  lion-jawed  (Fig.  325) 
and  Faraboeufs  forceps  (Fig.  32G)  are  excellent  instruments  for  grasp- 
ing the  bone  to  steady  the  part.  They  are  also  used  for  removing 
bone  by  twisting,  when  great  force  is  required. 

How  to  operate. — Before  beginning  an  amputation,  the  operator 
should  rehearse  in  his  mind,  at  least,  the  entire  procedure  as  he  con- 
templates it ;  by  doing  this  he  will  be  confident,  and  be  certain  to 
anticipate  the  unimportant  as  well  as  the  important  details.  The 
preparation  of  the  patient  and  administration  of  the  anaesthetic,  and 
methods  of  dressing,  are  given  on  the  pages  in  the  fore  part  of  this 
work.  The  surgeon  should  always  plan  his  work  with  careful  precis- 
ion, even  to  marking  out  upon  the  limb  the  outlines  of  the  flaps,  and 
such  other  incisions  as  may  be  required.  I  am  aware  that  this  is  sel- 
dom practiced,  even  by  the  most  experienced  surgeons ;  but,  within 
my  own  observations,  had  it  been  done  more  frequently  better  results 
might  have  been  secured.  The  young  surgeon,  too,  often  fancies  that 
to  do  this  announces  him  as  ignorant  and  inexperienced  ;  such,  however, 
is  not  always  the  case  ;  it  rather  serves  to  emphasize  his  cautious  and 
painstaking  qualities.  An  operation  should  be  done  without  haste, 
when  the  safety  of  the  patient  will  permit,  remembering  that  it  is  done 
quickly  when  done  well. 

The  operator  should  stand  in  such  a  relation  to  the  patient  that  the 
left  hand  can  readily  control  any  undue  hemorrhage  by  compressing 
the  artery,  or  otherwise. 

The  primary  incision  should  be  so  located,  if  possible,  that  the 
escaping  blood  will  not  obscure  the  course  of  the  incisions  to  be  subse- 
quently made. 

The  incision  which  will  divide  the  important  vessels  should  be 
made  last  when  practicable. 

In  circular  amputations  the  tissues  should  not  be  retracted  until 
after  the  division  of  the  integument. 

In  flaps  by  transfixion,  the  tissues  to  constitute  the  flap  can  be 
raised  or  depressed,  according  to  the  aspect  of  the  limb  from  which 
they  are  to  be  made. 

After  the  limb  is  removed,  the  open  mouths  of  the  vessels  should 
be  caught  by  nrrefines,  forceps,  etc.  The  tourniquet,  or  Esmarch's 
band,  is  then  loosened  slowly,  and  all  bleeding  points  controlled  by 
suitable  means  (Pig.  327).  The  surgeon  can  then  proceed  carefully  to 
ligature  the  vessels  thus  secured. 


236 


OPERATIVE   SURGERY, 


Fig.  328. — Retractor  for  two  bones. 


Fig.  329. — Retractor  for  one  bone. 


The  Retractor  is  made  of  linen,  or  ordinary  muslin,  torn  according 
to  the  size  and  anatomical  arrangement  of  the  limb  to  which  it  is  to 

be  applied.  If  for  two 
bones,  one  extremity  of 
the  retractor  should  be 
torn  into  three  strips 
(Fig.  328),  the  middle 
one  to  pass  between  the 
bones  (Fig.  330).  If 
for  one  bone,  the  re- 
tractor is  torn  partial- 
ly through  the  middle 
(Fig.  329),  and  applied 
as  shown  in  Fig.  331. 

AMPUTATIONS    OF    UP- 
PER  EXTREMITIES. 

330. — Three-tailed  retractor  applied.  General  Remarks. — 

In  all  the  amputations 
of  the  hand  and  fingers,  it  is  important  to  remember  that  usefulness 
and  symmetry  are  the  ends  to  be  attained.  If  strength  and  usefulness 
be  desiderata,  all  those  points  should  be  preserved  into  which  the 
muscles  and  ligaments  are  inserted,  which  endow  the  part  with  impor- 
tant functions. 


AMPUTATIONS. 


237 


It  therefore  be- 
comes imperative  for 
-the  surgeon  to  careful- 
ly study  the  functions 
of  the  muscles  associ- 
ated with  the  hand, 
and  to  preserve  as  care- 
fully as  possible  their 
points  of  insertion.  It 
is  a  well  -  established 
principle  that  every 
portion  of  the  hand  of 
a  laboring  man  which 
possesses  motion  and 
can  become  of  service 
to  him  should  be  saved. 
In  the  case  of  one 
whose  circumstances  or 
avocation  will  permit, 
the  sacrifice  of  useful- 
ness to  symmetry  may  be  made  with  the  concurrence  of  the  patient. 

Amputation  at  the  Phalangeal  Articulations. — Surgical  Anatomy. 
— The  first  row  of  surgical  phalanges  is  flexed  by  the  terminal  inser- 
tions of  the  flexor  profundus  digitorum;  the  second,  by  the  flexor  sub- 


Fig.  331. — Two-tailed  retractor  applied. 


Via,  "-Y-vl. — Attachments  of  tendons  to  phalanges.  1.  Extensor  communis  digitorum.  2. 
Fii-t  surgical  phalanx.  8.  Fibrous  bands  between  common  flexor  tendons  and  distal 
extremity  of  the  third  surgical  phalanx.  4.  Tendons  of  flexor  sublimus  digitorum, 
.r>.  Tendon  of  flexor  profundus  digatorum.  6,  Vincula  accessoria  tendinum.  7.  Head 
of  metacarpal  bone,  8.  .Joint  between  second  and  third  Burgical  phalanges.  9.  Joint 
between  Bret  and  second  surgical  phalanges. 


238 


OPERATIVE   SURGERY. 


limis  digitorum  ;  the  third,  by  the  flexor  sublimis,  through  the  vinculo, 
accessories  tendinum ;  by  dense  fibrous  bands  connecting  the  tendons 
of  the  flexor  sublimis  with  the  distal  extremity  of  that  phalanx  as  it 
passes  across  it ;  also  by  the  secondary  action  of  the  lumbrical  mus- 
cles (Fig.  332). 

The  Terminal  Phalanx  is  amputated  by  seizing  and  flexing  it  to 
a  right  angle  with  the  second  (Fig.  333)  ;  a  transverse  incision  is  then 


Fig.  333.— Flexed  phalanx.  Fig.  334.— Making  flap.  Fig.  335. — Flap  completed. 

made  on  its  dorsal  surface,  on  a  line  corresponding  to  the  center  of 
the  long  axis  of  the  second  phalanx,  which  will  open  the  joint ;  divide 
the  lateral  ligaments  with  the  point  of  the  knife,  separate  the  articular 
surfaces,  and  pass  the  blade  between  them,  then  cut  along  the  under 
surface  of  the  phalanx  to  be  removed,  close  to  the  bone  (Fig.  334),  far 
enough  to  make  a  palmar  flap  of  sufficient  length  to  easily  cover  the  end 
of  the  bone  (Fig.  335).  The  rule  previously  given  regarding  the  length 
of  flaps  will  enable  the  operator  to  meet  this  requirement.  If  the  at- 
tached extremity  of  the  flap  be  commenced  by  dividing  the  tissues  at 
each  side  of  the  phalanx,  for  three  or  four  lines,  down  to  the  bone, 
the  knife  can  follow  its  under  surface  without  the  danger  of  making 
the  attached  end  of  the  flap  too  narrow,  owing  to  the  extremities  of 

the      phalanges      being 
thicker  than  their  bodies. 
If  any  of  the  tissue  of 
the  flexor  tendon  be  in 
the  flap,  it  should  be  re- 
moved.    Tie  the  vessels, 
place  and  retain  the  flap 
in    position    by   two  or 
three    fine    sutures  and 
adhesive  strips  ;  or  dress 
antiseptically. 
Amputation  of  the  Second  Row  can  be  done  in  precisely  the  same 
manner  as  at  the  first,  or,  with  the  finger  extended,  by  making  a 
palmar  flap  first  by  transfixion  through  the  palmar  surface  opposite  the 
joint,  and  cutting  downward  until  a  well-rounded  flap  is  formed  (Fig. 


Fig.  336. — Flap  by  trans- 
fixion. 


Fig.  337.— Opening  joint. 


AMPUTATIONS. 


239 


336).     Then  carry  the  knife  upward  between  the  articular  surfaces 
and  through  the  soft  parts  on  the  dorsum  (Fig.  337). 

Either  of  the 
phalanges  may  be 
amputated  at  the 
center  by  a  short 
posterior  and  a  long 
inferior  or  palmar 
flap.  If  the  third 
surgical  (first  ana- 
tomical) phalanges 
be  amputated  at  the 
center,  the  power  of 
flexion  is  limited  to 
the  lumbrical  mus- 
cle, and  the  vincular 
tendons  connecting 
them  with  the  flex- 
or sublimis  digi- 
torum  (Fig.  332). 
When  symmetry  is  a 
secondary  consider- 
ation, this  amputa- 
tion may  be  made. 
In  the  case  of  the 
thumb,  the  index 
and  little  fingers, 
everything  possible 
addingto  the  length 
of  the  digit  should 
be  saved,  as  the  range  of  motion  of  the  thumb  and  little  finger  is  more 
extensive  than  the  others,  and  the  presence  of  the  index-finger  or  its 
stump  greatly  aids  the  crippled  thumb  in  the  performance  of  its 
functions. 

Amputation  at  the  Metacarpophalangeal  Articulation. — It  is  recom- 
mended by  some  that  this  operation  be  practiced  in  lieu  of  amputation 
at  the  middle  of  the  third  phalanges  (surgical)  of  the  second  and  third 
fingers,  or  even  disarticulation  between  their  second  and  third  pha- 
langes. I  am  satisfied,  however,  that  the  hand  will  be  far  stronger  if 
the  stumps  be  allowed  to  remain,  since  they  soon  become  easily  flexed 
and  extended,  and  the  continuance  of  these  motions  serves  to  stimu- 
late and  nourish  the  common  muscles  engaged  in  them,  and  thereby 
strengthens  the  power  of  the  remaining  finger.-'. 

Amputation  of  the  Second  or  Third  Finger.— This  is  done  by  the 
oval  flap,  which  should  Ij'j  marked  out  before  the  operation  is  oom- 


Fig.  338. — Amputating  middle  linger,  oval  flap. 


240 


OPERATIVE   SURGERY. 


menced  (Fig.  33S).  The  flaps  must  be  taken  from  the  finger  to  be 
removed,  and  should  be  of  generous  dimensions.  The  limit  of  the  in- 
cision above  corresponds  to  the  head  of  the  metacarpal  bone,  the  lower 
limit  to  the  transverse  line  of  the  palm  joining  the  fingers  to  the 
web.  Separating  widely  the  contiguous  fingers,  the  surgeon  seizes 
the  condemned  finger,  extends  it  well,  and  carries  the  incision  trans- 
versely along  the  line  beneath,  then  in  a  curved  direction  upward, 
along  the  side  of  the  finger  to  the  head  of  the  metacarpal  bone.  This 
incision  is  repeated  on  the  opposite  side  ;  the  tissue  carefully  divided, 
and  the  finger  removed  (Figs.  338,  339).  Better  drainage  will  be  se- 
cured if  this  flap  be  reversed  by  forming  its  retiring  angle  on  the 
palmar  instead  of  the  dorsal  surface  of  the  hand  (Fig.  340). 

Lateral-Flap  Operation. — This  is  best  adapted  to  the  thumb,  in- 
dex, and  little  fingers  (Fig.  340)  ;  it  can,  however,  be  employed  at 
the  ring  and  middle  fingers.  The  limit  of  the  dorsal  incision  is  the 
same  as  in  the  preceding.     The  lower  limit,  after  crossing  the  trans- 


Fig.  339. — Finsrer  removed. 


Fig.  340.— Lateral-flap  method.        Fig.  341.— Oval 

method. 


verse  line  of  the  web,  extends  toward  the  palm  about  a  third  of  an 
inch.     The  flaps  are  taken  from  the  sides  of  the  finger  to  be  removed. 

In  the  case  of  the  middle  and  ring  fingers  the  flaps  should  be  equi- 
lateral. For  the  thumb,  index,  and  little  finger,  that  portion  of  each 
against  which  pressure  is  most  liable  to  be  brought  should  be  covered 
by  a  longer  flap,  which  is  taken  from  the  outer  surface  of  the  index- 
finger,  from  the  inner  surface  of  the  little  finger,  and  from  the  palmar 
aspect  of  the  thumb,  the  base  of  the  flap  being  on  a  level  with  the 
joint.  The  longer  one  is  dissected  off,  after  which  the  smaller  one  is 
made.     Divide  the  ligaments  and  tendons,  and  remove  the  member. 

Amputation  of  the  Thumb  at  the  Carpometacarpal  Articulation. 
— Oval  MetJwd. — This  can  be  employed  equally  well  upon  the  thumb, 


AMPUTATIONS. 


241 


index,  and  little  fingers.  The  limit  of  the  dorsal  incision  in  either  in- 
stance is  the  proximal  extremity  of  the  metacarpal  bone  to  be  removed. 
Its  palmar  limit  is  the  transverse  line  at  the  junction  of  the  finger 
with  the  palm.  Begin  the  first  incision  at  the  base  of  the  metacarpal 
bone  of  the  thumb  (Fig.  341),  carrying  it  along  in  a  slightly  curved 
direction  to  the  outer  side  of  the  metacarpophalangeal  articulation  ; 
then  inward  through  the  line  of  the 
web.  The  second  one  joins  the  first 
near  the  base  of  the  metacarpal  bone, 
and  takes  a  corresponding  course 
along  the  inner  side,  meeting  the 
former  at  the  inner  extremity  of  the 
transverse  line  of  the  web.  The 
flaps  are  dissected  off,  and  the  artic- 
ulation between  the  metacarpal  bone 
and  the  trapezium  is  opened  from 
the  ulnar  side,  to  avoid  injuring  con- 
tiguous joints  (Fig.  342).  The  union 
of  the  flaps  leaves  a  linear  cicatrix 
(Fig.  343). 

The  Lateral-Flap  Method  (Fig. 
344). — This  method  can  be  more 
quickly  and  easily  performed  than 
the  former,  but  leaves  the  cicatrix 
in  a  less  advantageous  situation.  Abduct  the  thumb  and  enter  the 
knife  between  the  first  and  second  metacarpal  bones  ;  carry  it  up  be- 
tween them  with  a  sawing  motion,  till  the  head  of  the  first  is  reached. 

Cautiously  disarticulate  it  from  within 
outward  ;  increase  the  abduction,  and 
carry  the  blade  through  the  joint  and 
along  the  outer  side  of  the  metacarpal 


Fig.  342.—  Opening 
joint. 


Fig.  343.— Flaps 
united. 


I'i';.  844. — Lateral-flap  method. 
16 


Yv..  845.-  Making  outer  flap, 


242 


OPERATIVE   SURGERY. 


bone,  making  the  outer  flap,  which  should  terminate  opposite  the  web 
of  the  thumb  (Fig.  345). 

The  bases  of  the  metacarpal  bones  of  the  index,  middle,  and  little 
fingers  should  be  preserved  in  all  possible  instances,  as  they  afford 
attachment  to  the  important  extensor  and  flexor  muscles  of  the  carpus. 

Amputation  through  the  Metacarpal  Bones.  —  In  amputation 
through  two  or  more  of  these  bones,  the  principal  flap  should  be 
taken  from  the  palmar  surface,  although  it  may  be  taken  from  the 
border  and  palm  of  the  hand  (Fig.  346).    If  through  but  one  bone,  the 


Fig.  346. — Amputation  through  fourth 
and  fifth  metacarpal  bones. 


Fig.  34?. 


-Amputation  through  one  metacarpal 
bone. 


incisions  are  the  same  as  those  for  amputation  at  the  metacarpo-pha- 
langeal  articulation  by  the  oval  method,  the  only  difference  being  that 
their  upper  limit  will  correspond  to  the  point  of  proposed  section  of 
the  bone  (Fig.  347).  The  bone  is  exposed  by  reflection  of  the  soft 
parts  upon  the  point  of  proposed  section,  after  which  it  is  sawn 
through  with  either  a  chain-  or  metacarpal  bone-saw,  separated  from 
its  palmar  connections  and  removed  with  the  finger  attched.  If  a  saw 
be  not  convenient,  the  cutting  bone-forceps  (Liston)  can  be  used,  al- 
though with  some  risk  of  splintering  the  bone.  This  operation  is 
often  performed  in  preference  to  disarticulation  at  its  head,  in  order 
to  give  symmetry  to  the  hand  (Fig.  348). 

The  division  of  the  transverse  ligament,  which  extends  between 
the  heads  of  the  metacarpal  bones,  lessens  the  strength  of  the  grip. 


AMPUTATIONS. 


243 


This  operation  is,  therefore,  not  to  be  recommended  except  in  those  of 
sedentary  habits. 

Amputation  of  the  Last  Four  Metacarpal  Bones  (Disarticulation). 
(Fig.  34.9). — Make  a  semilunar  flap  from  the  palm  by  a  curved  incis- 
ion, beginning  at  the  web  of  the  thumb  and  terminating  at  the  ulnar 
border  of  the  fifth  metacarpal  bone.  This  flap  can  be  made  by  trans- 
fixion, if  desired  (Fig.   350).     The  dorsal  incision  (Fig.  351)  begins 

at  the  same  point  of  the 

web  of  the  thumb,  and  is 

\     carried  to  the  upper  third 

,.... -•- •"•'..  I   of  the  metacarpal  bone  of 

,---'-..-;>  \   I  j"':\  \  the     index  -  finger,    and 


Fig.  348. — Appearance  of  hand 
after  amputation  through 
third  metacarpal  bone. 


Fig.  349. — Line  of  palmar     Fig.  350. — By  transfixion. 


from  there  transversely  across  until  it  meets  the  ulnar  extremity  of 
the  first  incision.  The  flaps  are  now  reflected  up  to  the  carpo-meta- 
carpal  joint,  the  hand 
strongly  abducted,  and 
the  carpo  -  metacarpal 
joint  opened  from  the 
ulnar  side,  using  great 
caution  not  to  injure  the 
trapezium  and  the  meta- 
carpal bone  of  the  thumb. 
Without  the  thumb  thi3 
operation  would  be  of  lit- 
tle avail  in  securing  a  use- 
ful stump.  Unite  the 
flaps  with  interrupted  su- 
tures, introduce  a  drain- 
age-tube (Fig.  352),  and 
treat  anti.septically. 

The  results  of  ampu- 
tations of  the  thumb  and 


151. — Line  of  dorsal 
flap. 


Fio.  852.— Appear 
ance   of  Btump. 


244 


OPERATIVE   SURGERY. 


fingers  are  favorable ;  only  three  to  six  per  cent,  and  even  less,  with 
antiseptic  precautions,  die. 

Amputation  at  the  Wrist  (Disarticulation). — The  bones  enter- 
ing directly  into  this  articulation  are  the  radius,  scaphoid,  and  semi- 
lunar. The  location  of  the  joint  can  be  determined,  1,  by  forcibly 
bending  the  carpus  backward,  when  the  summit  of  the  angle  on  the 
dorsal  surface  formed  by  the  hand  and  forearm  indicates  the  radio- 
carpal joint ;  2,  by  drawing  a  line  transversely  from  one  styloid  pro- 
cess to  the  other — the  joint  is  about  one  fourth  of  an  inch  above  it. 
This  operation  can  be  done  by  either  the  circular,  single  palmar  or 
radial  flap,  or  by  the  double-flap  method. 

The  Circular  Method.—  Ascertain  one  fourth  of  the  circumference 


Fig.  353. — Circular  method. 


Fig.  354. — Flaps  united. 


at  the  articulation.  Measure  this  distance  downward  from  the  articu- 
lation, and  divide  the  soft  tissues  at  that  point  by  a  circular  incision  ; 
dissect  up  the  sleeve  of  integument  until  opposite  the  joint ;  pronate 
and  forcibly  flex  the  carpus,  and  open  the  wrist-joint  on  the  dorsal 
surface  by  an  incision  extending  between  the  styloid  processes  ;  divide 
the  lateral  ligaments,  pass  the  blade  through  the  articulation,  and 
sever  the  remaining  structures  (Fig.  353).  Unite  the  flaps  in  the  long 
axis  of  the  joint,  introduce  drainage-tubes  and  sutures,  and  dress  anti- 
septically  (Fig.  354). 

Double-Flap  Method  (Euysch). — Mark  out  the  distal  limits  of  the 
flaps  as  in  the  circular  method  ;  flex  and  pronate  the  hand  ;  carry  a 
semilunar  incision  over  its  dorsum,  beginning  at  the  styloid  process  of 
the  ulna  and  extending  to  the  circular  line  indicating  the  dorsal  ex- 
tent of  the  flap,  terminating  at  the  radial  styloid  process  (Fig.  355). 


AMPUTATIONS. 


245 


Fio.  355. — Makins:  dorsal  flap. 


Fio.  356. —  Making  anterior  flap. 


Dissect  up  the  flap,  allowing  the  tendons  to  remain  ;  flex  the  carpus 
firmly,  and  open  the  articulation,  as  in  the  circular  method  ;  carry 
the  hlade  of  the  knife  through  the  articulation  (Fig.  356)  and  make 
the  anterior  flap  by  cutting  outward. 

Single  Palmar  Flap. — This  method  is  easily  performed,  and  makes 
as  serviceable  a  stump  as  any.  Mark  out  a 
flap  on  the  palmar  surface,  semilunar  in 
shape,  and  about  three  inches  and  a  half 
in  length,  its  base  being  located  just  below 
the  apices  of  the  styloid  processes  (Fig. 
35T);  reflect  it  upward  ;  divide  the  remain- 
ing tissues  in  front  of  the  articulation  ; 
open  it.  passing  the  knife  through,  and 
making  a  short  dorsal  flap.  The  dorsal  flap 
can  be  made  first,  the  joint  opened  from 
behind,  and  the  long  anterior  flap  out  from 
the  joint  outward. 

Ra<l itd  Flap  (Dubrueil).  — Mark  out  a  flap,  semilunar  in  shape, 
the  base  of  which  shall  embrace  the  radial  third  of  the  carpus,  corre- 
sponding to  the  base  of  the  second  phalanx  of  the  thumb  (Fig.  358). 
Separate  the  thumb-flap,  then  connect  the  extremities  by  an  incision 
carried  transversely  around  the  ulnar  side,  draw  (he  skin  upward, 
open  the  joint  as  before,  remove  the  carpus,  and  properly  adjust  the 
Hap-  and  drainage-tube  (Fig.  359). 

Results. — The  rate  of  mortality  in  amputation  at  the  wrist-joint  is 
from  fifteen  to  thirty  per  cent  for  gun-shot  wounds,  being  about  eight 
per  ei nt  greater  than  for  amputation  through  the  tun. arm. 


1 1  \ 

Fio.  357. — Single  palmar  Hap. 


246 


OPERATIVE   SURGERY. 


VQIVqI 

Fig.  358.— Radial  flap. 


Fig.  359.— Ap- 
pearance of 
stump. 


It  therefore  follows  that  amputation  at 
the  wrist-joint  can  not  be  recommended,  on 
the  ground  of  safety  to  the  patient.  There 
are  other  objections  of  less  importance, 
which,  with  the  one  just  stated,  should  place 
the  operation  in  disfavor  with 
the    surgeon.      It    makes    a  •     |  ™ 

stump    which,  owing  to  the        ? 
feebleness  of   the  circulation        f 
in  the  flaps,  becomes  cold  and 
even    chilblained  ;    in   addi- 
tion, its  extremity  is  bulbous, 
thereby  interfering  with  the 
application   of    the   properly 
fitting  sockets  connected  with 
artificial  appliances. 
Amputation  of  the  Forearm.— The  forearm  is  best  amputated  by 
the  circular- flap  method  ;  although  the  equilateral  skin,  and  musculo- 
cutaneous flaps  are  often  employed. 

Circular  Amputation.  —Carefully  lay  out  the  length  of  the  pro- 
posed flap,  based  on  a  fourth  of  the  circumference.  Divide  the 
tissues  by  a  circular  incision  down  to  the  fascia  surrounding  the 
muscles  ;  the  integumentary  cuff  is  then  dissected  upward  by 
repeated  incisions  directed  toward  the  fascia  surrounding  the  mus- 
cles. 

If  the  cuff  be  too  small  to  be  turned  up  readily,  its  most  dependent 
part  when  dressed  can  be  slit  up.  After  the  flap  is  reflected  suffi- 
ciently, the  muscles  are  divided  half  an  inch  or  so  below  the  line  of 
its  reflection  by  a  circular  sweep  of  the  knife  down  to  the  bone,  the 
bone  sawn  off,  and  the  wound  dressed  in  the  usual  manner.  The  in- 
terosseous membrane  and  its  vessels  should  be  divided  a  short  distance 
below  the  point  of  proposed  bone  section  and  its  borders  separated 
from  those  of  the  contiguous  bones  up  to  the  point  of  section.  This 
avoids  the  risk  of  cutting  the  vessels  too  short,  as  when  they  are 
divided  at  a  level  with  the  bones,  which  permits  them  to  retract  above 
the  point  of  easy  access.  These  remarks  apply  with  equal  force  to 
amputation  of  the  leg. 

The  Equilateral  Skin-Flaps  are  raised  from  the  anterior  and  pos- 
terior, or  internal  and  external  surfaces  of  the  forearm  ;  the  latter  be- 
ing by  far  the  most  frequently  adopted.  Their  length  is  determined 
in  the  same  manner  as  in  the  circular  ;  in  fact,  if  the  circular  be  first 
done,  and  the  angles  of  the  cuff  trimmed  off  down  to  near  the  site  of 
the  muscular  section,  the  lateral  flaps  will  be  formed.  It  is  better, 
however,  to  mark  out  their  outlines  before  beginning  them  ;  since,  to 
make  each  with  the  same  curve  and  same  breadth  of  base  is  not  an 


AMPUTATIONS. 


247 


easy  tajk  without  this  precaution.     The  remaining  procedures  are  the 
same  as  those  of  the  circular  method. 

TJie  Musculo- Cutaneous  Flaps  are  made  by  transfixion  and  cutting 
outward  ;  in  other  respects  the  steps  do  not  differ  from  the  preceding 
operation. 

Results. — The  rate  of  mortality  in  amputation  of  the  forearm  is 
about  fifteen  per  cent  for  all  causes. 

Amputation  at  the  Elbow-Joint  (Disarticulation). — The  methods 
commonly  employed  are  the  circular  and  the  single  flap.  Before  op- 
erating, carefully  define  the  most  prominent  portions  of  the  condyles. 
Just  below  the  outer,  is  felt  the  movable  head  of  the  radius  ;  about  an 
inch  below  the  inner,  the  ulna  joins  the  inner  condyle  ;  the  articula- 
tion is  therefore  oblique,  the  inner  portion  being  about  half  an  inch 
the  lower,  owing  to  the  inner  condyle  being  that  much  longer  than 
the  outer. 

Circular  Method. — Lay  out  the  flaps  in  the  usual  manner,  measur- 
ing around  the  condyles.     Divide  the  superficial  tissues  down  to  the 

fascia  surrounding 
the  muscles,  as  be- 
fore ;  dissect  the 
flap  upward  to  a 
level  with  the  joiut, 


Fig.  860. — Amputation  at  elbow  joint. 


Fig.  3G1. — Circular  ampu- 
tation at  elbow. 


the  bony  indications  to  which  should  be  carefully  determined.  For- 
cibly extend  the  arm  and  make  an  incision  on  the  line  of  the  articula- 
tion (oblique)  down  to  and  into  it ;  sever  the  internal  and  external 
lateral  ligaments,  and  press  the  arm  still  farther  backward  ;  draw  the 


248 


OPERATIVE   SURGERY. 


olecranon  process  forward  into  the  wound,  and  sever  its  connection 
to  the  triceps  (Fig.  360).  Unite  the  borders  of  the  flap  as  indicated  in 
the  figure  (Fig.  361).  The  flaps  can  also  be  united  from  before  back- 
ward, which  causes  the  cicatrix  to  fall  letioeen  the  condyles,  and  like- 
wise increases  the  drainage  facilities — two  very  important  indica- 
tions. 

The  Single-Flap  Method. — This  flap  can  be  made  either  of  integu- 
ment and  subcutaneous  tissue  alone,  or  be  musculo-cutaneous,  and 
formed  by  transfixion.  In  either  instance  it  should  be  taken  from  the 
anterior  surface  of  the  forearm.  If  made  by  transfixion  (Fig.  362), 
supinate  and  flex  the  forearm  slightly,  raise  the  soft  parts  in  front  of 
the  joint,  and  enter  the  knife  an  inch  below  the  inner  condyle,  pass  it 

in  front  of  the  bones  obliquely  outward, 
causing  it  to  escape  about  one  inch  and 
a  half  below  the  outer  condyle.  Cut 
the  anterior  flap  downward  and  outward, 
making  it  about  three  inches  and  a  half 
in  length  ;  dissect  and  draw  the  flap  up 
to  a  level  with  the  joint  in  front.  Make 
the  posterior  flap  by  connecting  the  ex- 
tremities of  the  first  incision  by  a  trans- 
verse one  (Fig.  363),  and  dissect  this  up, 
after  which  the  joint  is  opened  in  front ; 
the  lateral  ligaments  divided,  olecranon 
process  displaced  forward,  and  the  tri- 
ceps cut  off.  It  is  advisable,  when  pos- 
sible, to  saw  off  the  olecranon,  allowing 
it  to  remain  with  the  triceps  attached. 
The  stump  will  be  stronger  if  it  be  pos- 
sible to  sever  the  ulna  below  the  inser- 
tion of  the  brachialis  anticus,  allowing 
the  fragment  to  remain  along  with  its 
muscular  attachments.  In  amputations 
near  the  elbow,  the  tubercle  of  the  ra- 
dius, together  with  the  biceps  tendon 
inserted  into  it,  should  be  carefully  pre- 
served. 
Results. — The  deaths  from  this  amputation  vary  from  thirteen  to 
twenty  per  cent  without  antiseptic  treatment. 

Amputation  of  the  Arm.— Either  the  circular,  double  flap,  or  the 
single  circular  incision  method  of  Celsus  can  be  employed.  The  former 
is  usually  preferred.  In  the  second,  the  flaps  may  be  antero-posterior, 
or  lateral ;  integumentary  alone,  or  combined  with  muscular  tissue. 
The  single  circular  operation  is  seldom  employed  at  the  arm. 

Gircular-Flap  Method.— Plan  the  length  of  the  flap  upon  the  cir- 


Fig.  362. — Flap  by  transfixion. 


Fig.  363. — Making  posterior  flap. 


AMPUTATIONS. 


249 


eumference  of  the  limb  at  the  point  of  proposed  section.  Divide  the 
superficial  tissues  down  to  the  muscular  fascia,  and  turn  the  flap  up  as 
elsewhere  ;  then  divide  the  muscles  down  to  the  bone,  about  an  inch 
below  the  reflection  of  the  flaps.  Apply  the  two-tailed  retractor,  saw 
through  the  bone  opposite  the  point  of  reflection  of  the  flap,  and  unite 
the  flaps  in  the  direction  best  calculated  to  provide  dependent  drainage. 
Unequal  Double-Flap  Method. — If  skin  alone  be  used,  the  flaps 
should  be  carefully  mapped  out  upon  the  integument  of  the  arm,  in 
the  general  manner  before  described.  Dissect  them  up,  and  make  a 
circular  section  of  the  muscles  down  to  the  bone  ;  unite  the  flaps,  and 
dress  the  stump  as  before. 

If  Musculo- Cutaneous  Flaps  (Langenbeck)  be  desired,  they  can  be 
made  by  transfixion  from  within  outward,  or  with  a  scalpel  from  with- 
out inward.     The  latter  plan  secures  the  more  uniformity  of  outline 

in  the  flap.     If  they  are  to  be 
>  made  from   without   inward, 

first  mark  them  out  carefully, 


/ 


then  with  a  sharp  scalpel  form 
them  as  planned  (Fig.  364)  ; 
when  dissected  up  the  desired 


Via.  864. — Lancenbcck'i  method. 


Fin.  865.— Unequal  ikl 


250 


OPERATIVE   SURGERY. 


distance,    complete   the   operation   by   dividing   the    muscles   as   be- 
fore. 

Large  Anterior  and  Small  Posterior  Shin-Flaps  are  sometimes 

made  (Fig.  365),  also  a 
large  anterior  one,  with 
a  posterior  circular  in- 
cision (Fig.  366).  They 
possess  the  advantage  of 
good  drainage,  and  of 
placing  the  cicatrix  where 
it  is  well  removed  from 
irritation.  The  outline 
of  these  flaps  can  be  easi- 
ly estimated  on  the  same 

.   basis  as  if  they  were  to  be 

equal  in  length — viz.,  if 
one  be  proportionately 
increased  in  length,  the 
other  is  to  be  shortened. 
Results. — The  death- 
rate  from  amputation  of 
the  arm  varies  somewhat 
according  to  the  seat  of 
the  operation.  It  is  about 
eighteen  per  cent  when 
done  in  the  upper  third, 
sixteen  per  cent  at  the 
middle  third,  and  about  twenty-six  per  cent  at  the  lower  third — the 
greater  per  cent  in  this  situation  being  due,  no  doubt,  to  the  greater 
degree  of  injury  calling  for  it  at  this  point.  If  done  for  disease,  the 
percentage  would  no  doubt  be  reversed. 

Amputation  at  the  Shoulder-Joint  (Disarticulation). — There  are 
various  methods  recommended  for  amputation  at  this  joint.  It  is 
hardly  necessary  to  enter  into  the  details  of  more  than  two  or  three  of 
those  commonly  recognized  and  employed.  The  remainder,  while 
ingenious  in  many  instances,  do  not  present  differences  of  enough 
practical  worth  to  be  introduced  into  a  hand-book  of  operative  surgery. 
Amputation  ly  Internal  and  External  Flaps  (Dupuytren). — Place 
the  patient  on  the  edge  of  the  table,  partially  upon  the  healthy  side, 
with  the  body  raised.  An  external  oval  flap  is  made  by  an  incision 
extending  from  the  coracoid  process  downward  and  outward  to  the 
insertion  of  the  deltoid  ;  then  upward  and  backward,  terminating  at 
the  junction  of  the  acromion  process  with  the  spine  of  the  scapula 
(Fig.  367).  The  flap,  including  the  deltoid  muscle,  is  now  raised  as 
far  as  the  acromion,  turned  back,  and  the  capsule  of  the  joint  exposed, 


Fig.  366. — Long  anterior  flap. 


AMPUTATIONS. 


251 


the  head  of  the  humerus  pushed  upward,  capsule  divided  above  ;  then 
the  arm  is  rotated  outward  and  the  subscapulars  severed  ;  then  in- 
ward, followed 
by  the  rapid  di- 
vision of  the  ex- 
ternal rotators 
attached  to  the 
greater  tuberos- 
ity. While  the 
arm  is  rotated 
internally,  the 
capsule  is  still 
further  divided, 
together  with 
the  tendon  of 
the  long  head  of 
the  biceps,  the 
head  of  the  hu- 
merus tilted  out- 
ward, and  the 
blade  of  the 
knife  passed  be- 
neath it  (Fig. 
368)  ;  the  head 
of  the  bone  is 
then  seized  and 
drawn  outward, 
and  the  knife 
carried  along  its 
inner  surface 
until  within 
about  four  inch- 
es below  the  ax- 
illary fold,  when 
ite  edge  is  turned 
inward  and  the 
flap  completed. 
The  last  sweep 
of  the  knife  sev- 
ers the  principal 
and  this 
flap    should    be 

seized  by  an  assistant  and  tightly  grasped  before  it  is  completed.    The 

els   in   this  operation  an-  controlled  by  cither  pressure  upon  the 

third   portion    of   the  subclavian,  or  by  the  elastic  hand  arranged  as 


],,,.  :;c,7. — Disarticulation  of  shoulder-joint. 


252 


OPERATIVE   SURGERY. 


shown  in  the  illustration.     The  appearance  of  the  wound  after  the 
operation  is  apparent  from  Fig.  369. 

Amputation  by  Circular  Incision. — Control  the  circulation  as  be- 
fore. Abduct  the  arm  and 
make  a  circular  incision  entirely 
around  it  through  all  the  tis- 
sues, down  to  the  bone,  at  a  |  '  Jf 
point  corresponding  to  the  in- 
sertion of  the  deltoid.     Saw  off 


Fig.  368. — Making  inner  flap. 


I 

Fig.  369.— Flaps  united. 


the  bone  and  ligature  the  vessels.  Make  a  second  incision  longitudi- 
nally, from  the  anterior  border  of  the  acromion,  the  whole  length  of  the 
stump,  down  to  the  bone.  The  bone  is  then  held  firmly  and  the  soft 
parts  separated  from  it  (Fig.  370),  after  which  it  is  rotated  outward, 
then  inward,  to  admit  of  the  division  of  the  muscular  and  fibrous  at- 
tachments to  its  head,  when  it  can  be  removed.  This  is  a  good  oper- 
ation and  well  calculated  to  provide  favorable  drainage  (Fig.  371),  and 
is  done  with  a  minimum  amount  of  injury  to  the  soft  parts.  If  the 
periosteum  be  separated  from  the  bone  without  disturbing  the  sur- 
rounding soft  parts,  there  will  be  less  danger  of  the  extension  of  in- 
flammatory action  beyond  the  line  of  the  longitudinal  incision  ;  more- 
over, a  greater  degree  of  firmness  will  be  given  the  stump,  even  though 
new  bone  be  not  produced. 

Oval  Method  (Larrey). — This  method  is  well  thought  of,  and  is 
performed  by  making  a  vertical  incision  from  the  extremity  of  the 
acromion  process,    with  the  arm  extended,   about   three  inches  in 


AMPUTATIONS. 


253 


Fig.  370. — Removing  the  bone. 


length  down  to  the  bone ;  this  incision  should  terminate  about  one 
inch  below  the  head  of  the  humerus.  Two  oblique  incisions  are  then 
made,  each  beginning  near  the  middle  of  the  vertical  cut,  one  on  the 
anterior  and  the  other  on  the  posterior  aspect  of  the  limb  ;  these,  when 
carried  through  the  structures  composing  the  anterior  and  posterior 
walls  of  the  axilla,  to  the  lower  border  of  each,  divide  their  attachments 
to  the  humerus  (Fig.  372).  The  soft  parts  at  the  inner  side  of  the 
humerus  still  remain  undivided.  The  borders  of  the  wound  are  now 
drawn  apart,  the  joint  exposed  and  opened  above  ;  the  bone  drawn 
downward  to  separate  the  joint  surfaces,  and  the  blude  of  the  knife 
passed  between  them,  behind  the  luxated  bone,  and  the  operation 
completed  by  cutting  the  remaining  tissues  at  the  inner  side  of  the 
humerus  intervening  between  the  lower  extremities  of  the  incisions 
previously  made  (Fig.  373). 

8periC(?8  Method  has  attracted  considerable  attention,  and  is  cer- 
tainly entitled  to  additional  consideration. 

It  does  not  possess  any  practical  advantages  over  the  method  by 
circular  incision.     It  is  done  in  the  following  manner  :  Abduct  the 


254 


OPERATIVE   SURGERY. 


outer  side. 


arm  slightly ;  rotate  the 
humerus  outward  ;  cut 
down  upon  the  head  of 
the  bone,  beginning  im- 
mediately external  to  the 
coracoid  process,  thence 
directly  downward 
through  the  fibers  of  the 
deltoid  and  pectoralis  ma- 
jor to  the  lower  border  of 
the  latter,  which  is  di- 
vided ;  carry  the  incision 
with  a  gentle  curve  out- 
ward across  and  through 
the  lower  fibers  of  the  del- 
toid, to,  but  not  through, 
the  posterior  border  of 
the  axilla  (Fig.  374).  Be- 
gin the  inner  incision  at 
the  lower  extremity  of 
the  vertical  one,  carry  it 
around  the  inner  side  of 
the  arm,  through  the 
skin  and  fat  only,  to 
meet  the  one  made  at  the 
If  the  fibers  of  the  deltoid  have  been  thoroughly  divided, 


Fig.  371. — Flaps  united. 


Fig.  372. — Larrey's  method.        Fig.  373. — Forming  inner  flap.     Fig.  374.— Spence's 

method. 


the  flap,  together  with  the  posterior  circumflex  artery,  can  be  easily 
separated  by  the  finger  from  the  bone  and  joint,  and  drawn  upward 


AMPUTATIONS   OF  THE   LOWER   EXTREMITY.  255 

and  backward  until  the  head  of  the  bone  is  exposed  ;  then  the  liga- 
ments and  muscular  attachments  are  divided,  disarticulation  accom- 
plished, and  the  limb  removed  by  dividing  the  remaining  soft  parts  at 
the  axillary  aspect. 

In  very  muscular  subjects,  a  redundancy  of  that  tissue  in  the  flap 
can  be  avoided  by  dissecting  the  integument  and  subcutaneous  tis- 
sues a  short  distance  upward  over  the  deltoid,  and  dividing  its  fibers 
high  up. 

Results. — The  rate  of  mortality  varies  from  twenty-five  to  thirty- 
eight  per  cent  for  gun-shot  injuries. 

Amputation  above  the  Shoulder-Joint. — It  may  become  necessary, 
on  account  of  malignant  growths  and  severe  injuries,  to  amputate  the 
scapula  together  with  a  portion  or  the  whole  of  the  clavicle. 

The  operation  is  often  tedious  and  attended  with  great  loss  of 
blood.  Inasmuch  as  the  situation  of  the  disease  or  injury  calling  for 
it  will  modify  the  location  and  direction  of  the  incisions,  no  definite 
plan  can  be  prescribed.  However,  the  aim  should  be  always  to  save 
enough  healthy  integument  to  cover  the  wound  and  to  avoid  hemor- 
rhage. 

Results. — Fifty-one  cases  are  reported,  with  a  mortality  of  twenty- 
five  and  a  half  per  cent. 


CHAPTER  X. 
AMPUTATIONS   OF  THE  LOWER  EXTREMITY. 

!No  better  or  more  comprehensive  statement  can  be  made  bearing 
on  the  duty  of  the  surgeon  in  amputations  of  the  lower  extremity, 
than  that  "  under  all  circumstances,  except  where  poverty,  advanced 
age,  and  confirmed  dissolute  habits  so  combine  in  the  individual  as  to 
render  it  certain  that  mechanical  appliances  would  be  of  little  service, 
give  the  patient  the  stump  best  adapted  to  the  most  useful  artificial 
limbs.  In  all  amputations  of  the  lower  extremity,  the  surgeon  should 
be  governed  in  the  selection  of  the  point  of  operation  and  the  method 
to  be  adopted  by  the  mortality  of  the  operation  in  question  ;  by  the 
adaptability  of  the  stump  to  the  most  serviceable  artificial  limb  for 
locomotion."* 

Amputation  of  the  Phalanges  in  their  Continuity,  or  through  the 
articulation.-,  is  done  by  the  same  rules  as  those  applied  to  amputation 
of  the  fingers.     In  the  case  of  the  toes,  however,  it  is  often  difficult 

*  From  report  of  Drt.  Valentine  Mott,  (lunlon  Buck,  John  Watson,  A.  C.  Post,  Wil- 
lard  Parker,  Ernst  Kraekowizer,  W.  II.  Van  liurcn,  and  Stephen  Smith. 


256 


OPERATIVE   SURGERY. 


to  open  the  joints  on  account  of  the  changes  induced  in  them,  and  in 
the  contour  of  the  bones,  by  the  pernicious  influence  of  illy  fitting 
boots  and  shoes.  The  flaps  are  made  from  the  plantar  surface.  In 
amputation  at  the  metatarsophalangeal  articulations,  remember  the 
relation  of  the  web  to  the  joints  in  question,  the  former  being  a  con- 
siderable distance  below  the  latter  (Fig.  375). 

Amputation  of  Single  Toes  (disarticulation). — They  can  be  re- 
moved by  the  oval  or  by  the  lateral-flap  method. 
The  former  is  the  better,  and  is  done  by  first 
grasping  the  condemned  toe,  while  the  assistant 
pulls  aside  its  fellows.  Commence  the  incision  on 
the  dorsum  over  the  joint,  carry  it  downward  along 
the  side  of  the  phalanx  to  be  removed,  beneath 


\  ft     i     i     >\    1    ' 

i  \\    !\     J,    ; \   |  ,' 


Fig. 


3*76. — Removal    of 
single  toe. 


Fig.  377. — Lateral-flap 
method. 


Fig.  375. — Incision  for 
amputation  at  meta- 
tarso-phalangeal ar- 
ticulation. 

the  toe  through  the  line  of  the  web  to  the  sole  of  the  foot.  A  second 
incision  is  then  made  of  a  similar  extent  and  outline  on  the  opposite 
side  of  the  toe,  down  to  the  bone  (Fig.  376).  The  ligaments  are  di- 
vided, the  tendons  are  cut  off,  and  the  bone  removed  by  cutting  from 
below.  If  the  extremities  of  the  divided  tendons  remain  exposed, 
they  are  pulled  down  and  severed  on  a  level  with  the  divided  border 
of  the  soft  parts. 

The  removal  of  either  the  second,  third,  or  fourth  toes  can  be 
effected  by  making  a  transverse  incision  on  the  dorsum  over  the  joint, 
and  passing  the  knife  through  it  and  along  the  under  surface  of  the 
bone  a  sufficient  distance  to  make  the  necessary  plantar  flap,  which  is 
turned  upward  and  united.  If  it  be  required  to  remove  the  whole  or 
part  of  the  metatarsal  bone  of  either  of  these  toes,  the  dorsal  incisions 
of  the  oval  flap  for  disarticulation  have  only  to  be  extended  upward 
on  the  dorsal  surface  of  the  bone  to  be  removed,  to  the  point  of  in- 
tended section  (Fig.  376). 

The  lateral  flap  is  better  for  the  disarticulation  of  the  great  and 


AMPUTATIONS  OF  THE  LOWER  EXTREMITY. 


257 


Fig.  379. — Square-flap 
method. 


little  toes  (Fig.  377),  and  is  made  by  abducting  the  toe  and  entering 
the  knife  vertically  between  it  and  the  contiguous  toe,  and  cutting 
through  the  web 
till  the  line  of 
articulation  is 
reached,  when 
the  knife  is 
turned  outward 
from  the  median 
line  of  the  foot, 
joint  opened, 
blade  pa  ssed 
through  it,  and 
the  lateral  flap 
made  of  sufficient 
length  by  cutting 

along  the  opposite  side  of  the  toe  (Fig.  378)  to 
be  removed.  The  importance  of  the  great  toe  as 
a  lever  in  propelling  the  body,  requires  that  am- 
putation through  its  phalanges  be  practiced  when 
possible.  With  the  remaining  toes,  however,  it 
is  not  a  matter  of  so  much  importance. 

The  prominent  head  of  the  metatarsal  bone  of  the  great  toe,  which 
remains  after  disarticulation,  has  so  frequently  become  the  seat  of 
painful  bunions,  that  many  surgeons  of  prominence  advise  that  the 
bone  be  amputated  behind  its  head  by  either  a  transverse  or  oblique 
section  of  its  shaft.  Of  one  fact  there  can  be  no  doubt  :  if  that  por- 
tion of  the  boot  or  shoe  in  contact  with  this  stump  be  not  fitted  to  it 
and  kept  elevated  by  some  means,  the  leather  will  in  a  short  time  press 
upon  it,  cause  great  annoyance,  and  cripple  the  patient  unnecessarily. 

The  great  toe  can  be  amputated  by  a  large  square  internal  flap  (Fig. 
379)  and  by  the  oval  method  (Fig.  375).  Begin  the  longitudinal  in- 
cision at  the  outer  side  of  the  exteusor  tendon  a  little  below  the  joint ; 
carry  it  through  the  tissues  down  to  the  first  phalanx  (surgical)  ;  make 
a  transverse  incision  from  the  termination  of  this  one  around  the  inner 
side  of  the  toe  to  a  point  opposite,  on  the  plantar  surface  ;  extend  the 
toe  and  make  another  incision  from  the  termination  of  the  last  toward 
the  foot  along  the  outer  side  of  the  tendon  of  the  flexor  longus  pollicis 
to  the  web  ;  connect  this  with  the  center  of  the  dorsal  one  by  a  trans- 
cul  carried  around  the  outer  side  of  the  base  of  the  toe  ;  dissect 
off  th<-  flaps  and  divide  the  ligaments  and  the  remaining  soft  parts 
from  within  outward.  The  <>val  method  is  performed  in  a  similar 
manner  to  the  same  method  when  applied  to  the  fingers. 

Amputation  of  Two  Adjoining  Toes. — Begin  the  dorsal  incision 
between   the-  metatarsal  bones  of  the  toes  to  be  removed,  just  below 
17 


258 


OPERATIVE   SURGERY. 


the  joint,  where  the  bones  are  to  be  divided  ;  carry  it  to  the  outer  side 
of  one  of  the  toes  to  be  removed,  taking  a  good-sized  flap  from  it, 
thence  through  the  digito-plantar  fold  to  the  outer  side  of  the  remain- 
ing toe,  back  to  the  point  of  starting.  Eemove  each  toe  separately  in 
the  usual  manner,  and  close  the  wound. 

Amputation  of  all  the   Toes   at  the   Metatarsophalangeal  Joint 

{Disarticulation).  —  Forcibly  ex- 
tend the  toes  with  the  left  hand, 
and  make  a  curved  incision  on  the 
plantar  surface  from  the  inner 
side  of  the  articulation  of  the  great 
toe,  to  the  outer  side  of  the  corre- 
sponding joint  of  the  little  toe, 
carrying  it  through  the  groove  be- 
tween the  sole  of  the  foot  and  the 
base  of  the  toes  (Fig.  380).  Flex 
the  toes  and  join  the  first  incision 
by  a  similar  one  across  the  dorsum 
(Fig.  381).  Dissect  up  the  flaps, 
expose  the  joints,  and  remove  each 
toe  separately,  allowing  the  sesa- 
moid bones  of  the  great  toe  to  re- 
main. If  the  flaps  be  too  short,  the  heads  of  the  metatarsal  bones 
should  be  cut  off  sufficiently  to  permit  proper  adjustment,  and  the 


Fig.  380. — Plantar  incision. 


'i-Si- ->.,■-;;. 


•Dorsal  incision. 


divided  surfaces  united.    When  recovery  takes  place,  the  foot  presents 
the  following  appearance  (Fig.  382). 

Amputation  through  all  the  Metatarsal  Bones.—  This  is  best  done 
by  a  short  dorsal  and  a  long  plantar  flap.  Make  the  plantar  flap  first, 
dissecting  the  tissues  backward  down  to  the  bones,  from  the  junction 
of  the  toes  with  the  sole,  to  the  point  of  amputation.  A  short  dorsal 
flap  is  then  made  with  the  convexity  downward,  its  extremities  being 
united  to  those  of  the  preceding.     Divide  the  interosseous  tissues  with 


AMITTATIOXS   OF   THE   LOWER   EXTREMITY. 


259 


a  sharp,   narrow-bladed  knife  ;    introduce  a  carbolized  six-tailed  re- 
tractor (Fig.  383),  draw  the  soft  parts  upward,  and  divide  the  bones 


Fir.  382. — Appearance  of  stump. 


Fig.  383. — Pawinjr  the  bones. 


-This 


IS 


Fig.  384. — Amputation  at  proximal  end  of 
metatarsal  bone. 


with  a  fine  saw,  and  turn  the  plantar  flap  upward  and  unite  it  in  the 

usual  manner. 

Amputation  of  the  Great  Toe  with  its  Metatarsal  Bone. 

best  done  by  the  oval  method 

(Fig.  384),  which  is  similar  to 

that  for  removal  of  the  thumb. 

It  is  recommended,  on  account 

of  the  width  of  the  base  of  the 

metatarsal  bone,  to  make  a  short 

transverse  incision  across  it  at 

the    joint  ;    remove    the     flap, 

thereby    exposing     the     whole 

length  of  the  bone ;  open  the 

joint  on  the  dorsal  aspect,  sep- 
arate its  remaining  connections,  and  remove  it. 

Amputation  of  the  Fifth 
Toe,  with  the  Metatarsal 
Bone. — This  can  be  done 
by  either  the  oval  or  later" 
al-flap  method  ;  the  steps 
of  the  former  being  in  all 
respects  substantially  simi- 
lar to  those  for  the  removal 
of  the  great  toe. 

The  lateral-flap  method 
is  done  by  separating   the 


Vi<;   885. — Amputation  of  little  toe  and  metatarsal 
bone. 


260 


OPERATIVE   SURGERY. 


Fig.  386. — a,  a.  Line  of  Lisfranc's  amputation,  b. 
Line  of  Hey's  modification  of  Lisfranc's  amputa- 
tion, c.  Line  of  Skey's  modification  of  Lisfranc's 
amputation,  d.  Line  of  Baudens'  modification 
of  Lisfranc's  amputation,  e,  e.  Line  of  Forbes' 
amputation.  /,  /;  /,/.  Lines  of  Miculicz's  am- 
putation,    ff,  g.  Lines  of  Chopart's  amputation. 


fifth  from  the  fourth  toe, 
at  the  same  time  carrying 
a  narrow-bladed  knife  up- 
ward between  the  meta- 
tarsal bones  from  the  web, 
until  it  is  obstructed, 
when  the  knife  is  with- 
drawn and  the  incision 
prolonged  upward  on  the 
dorsal  and  plantar  sur- 
faces in  a  straight  line 
about  one  inch.  Strongly 
abduct  the  metatarsal 
bone  to  be  removed,  sepa- 
rating it  from  its  fellow 
and  from  the  cuboid  ; 
carry  the  knife  around 
the  base  to  the  outer  side, 
and  so  on  downward  to 
the  metatarso-phalangeal 
articulation  (Fig.  385)  ; 
remove  the  bone,  and  the 
tongue  -  shaped  flap  just 
made  will  fit  the  inter- 
metatarsal  incision. 

Amputation  at  the 
Tarso  -  metatarsal  Joints 
(Lisfranc's). — It  will  very 
much  expedite  matters, 
save  considerable  annoy- 
ance to  the  operator,  and 
preserve  the  edge  of  his 
knife,  if  the  relations  of 
the  bones  entering  into 
the  joints  be  fully  noted 
before  attempting  to  open 
them  (Fig.  386).  The  ar- 
ticulation between  the  cu- 
boid and  the  fifth  meta- 
tarsal is  seen  to  be  to  the 
inner  side  of  its  tuberosity. 

The  joint  of  the  inter- 
nal cuneiform  and  the 
metatarsal  bone  of  the 
great  toe  is  about  an  inch 


AMPUTATIONS  OF  THE  LOWER  EXTREMITY. 


261 


%7, 


and  a  half  iu  front  of  the  tuberosity  of  the  scaphoid,  and  the  head  of 
the  second  metatarsal  bone  is  lodged  between  the  three  cuneiform 
bones.     In  every  instance  these  joints  must  be  carefully  located. 

Operation. — Raise  the  foot  and  mark  out  a  large  semilunar  flap  on 
the  plantar  surface,  the  base  of  which  shall  correspond  to  the  distance 
between  the  joints  just 
indicated,  and  its  distal 
extremity  to  the  heads  of 
the  metatarsal  bones.  Ex- 
tend the  foot,  and  make 
a  short  dorsal  flap  with 
the  convexity  forward, 
and  its  base  corresponding 
to  that  of  the  plantar  flap 
(Fig.  387).  Draw  the 
small  dorsal  flap  upward, 
and  commence  the  disar- 
ticulation at  the  outer 
side  of  the  tarsus  ;  strong- 
ly extend  and  adduct  the 
bones,  which  will  better 
mark  the  outlines  of  the 
articulation  ;  separate  the 
fifth,  fourth,  and  third 
articulations ;  skip  the  second  and  open  the  first.  The  articulation 
of  the  second  with  the  cuneiform  bones  is  peculiar,  in  that  it  is  about 

two  fifths  of  an  inch 
higher  (Fig.  388)  ; 
however,  with  the 
bones  depressed,  a 
short  transverse  in- 
cision liberates  its 
dorsal  connections 
with  the  middle  cu- 
neiform, after  which 
it  is  disconnected 
from  the  internal 
and  external  cunei- 
form bones,  as  well 
as  its  contiguous 
metatarsal,  by  cutting  upward  (Fig.  389).  Open  the  joint  well,  divide 
the  ligaments  on  the  Bide  and  plantar  surface,  carry  the  knife  along 
the  sole,  and  make  the  plantar  flap  as  previously  laid  out  (Fig.  .'5'.tn). 
If  all  the  muscular  tissues  of  the  Bole  be  removed,  it  will  be  too  bulky; 
a  part  should  therefore  be  om if t f<l  from  it. 


Fig.  3S7.— Dorsal  flap.     Fig.  388. — Articulation  of 
second  metatarsal. 


189. — Separating  second  metatarsal. 


262 


OPERATIVE   SURGERY. 


The  plantar  flap  may  be  made  by  transfixion,  before  the  articula- 
tions are  opened  ;  this  method  can  not  be  recommended,  however,  as 

the  flaps  thus  formed  must  await  the 
completion  of  the  operation  without 
facilitating  it.  Moreover,  if  the  plan- 
tar flap  be  made  by  transfixion,  before 
disarticulation,  the  transverse  arch  of 
the  foot  will  be  intact,  causing  the 
center  of  the  flap  to  be  made  thin, 
since  the  knife  can  not  come  suffi- 
ciently close  to  other  than  the  first 
and  fifth  metatarsal  bones.  After  the 
removal  of  the  part,  the  flap  appears 
as  seen  in  Fig.  391.  This  method 
has  been  variously  modified,  the  mod- 
ifications, in  some  instances,  becom- 
ing confused  with  the  original  meth- 
od. Hey  sawed  off  the  projecting 
portion  of  the  internal  cuneiform  ;  this,  however,  is  not  expedient,  as 
it  lessens  the  attachment  of  the  tibialis  anticus  and  shortens  the  lever- 
age of  the  foot. 

Skey  sawed  off  the  base  of  the  second  metatarsal,  leaving  it  in  the 
mortise.  This  adds  nothing  to  the  usefulness  of  the  stump,  and  ex- 
poses the  remaining  fragment  to  the  danger  of  necrosis. 

Baudens  proposed  that  the  first  metatarsal  bone  only  should  be 
disarticulated,  and  the  remaining  ones  sawn  off  transversely  on  a  level 
with  the  internal  cuneiform. 

Reported  as  Results. — The  rate  of  mortality  in  amputation  of  the 
toes  is  about  six  per  cent. 

Amputation  through  the  Medio-tarsal  Joint  (Chopart's). — The  me- 


Fig.  390. — Making  plantar  flap. 


Fig.  391. — Appearance  of  flap 
(after  Lisfranc's  amputation).  Fig.  392. Inner 

dio-tarsal  joint  is  formed  by  the  astragalus  and  os  calcis  behind,  and 
the  scaphoid  and  cuboid  bones  in  front. 

This  articulation  can  be  located  by  drawing  a  transverse  line  across 


AMPUTATIONS  OF  THE  LOWER  EXTREMITY. 


2G3 


Fig.  393. — Inferior1  aspect. 


the  dorsum  of  the  foot,  beginning  just  behind  the  tuberosity  of  the 
scaphoid  ;  the  outer  extremity  will  be  about  one  inch  behind  the  tu- 
berosity of  the  fifth  metatarsal  bone.  The  foot  is  raised  and  a  curved 
iucisiun  is  carried  over  the  sole,  extending  from  the  articulation  of  the 
scaphoid  with  the  astragalus  (Fig.  392),  forward  to  within  a  thumb's 
breadth  of  the  heads  of 
the  metatarsal  bones 
(Fig.  393),  then  across 
the  sole  and  backward  to 
the  outer  extremity  of 
the  articulation  of  the 
cuboid  and  os  calcis  (Fig. 
394).  Forcibly  extend 
the  foot  and  make  a 
slightly  curved  incision, 

through  the  skin  only,  the  convexity  downward,  across  the  dorsum, 
connecting  the  upper  extremities  of  the  plantar  incision  (Fig.  395). 

Turn  the  dorsal  flap  up- 
ward, open  the  joint  on  the 
dorsal  surface  ;  beginning 
from  within,  bend  the  met- 
atarsal bones  toward  the 
heel,  and  sever  the  ligamen- 
tous connections  thus  made 
tense.  Finally,  pass  the 
knife  through  the  articula- 
tion to  the  plantar  surface, 
turn  the  edge  toward  the 
toes,  and  complete  the  plan- 
tar flap  (Fig.  39G).  Fig. 
397  represents  the  stump  after  the  flaps  are  united. 

This  operation  is  objected  to  on  account  of  the  liability  of  the 
stump  to  become  extended,  causing  the  patient  to  walk  on  the  cicatrix 
at  its  anterior  extrem- 
ity. The  division  of 
the  tendo  Achillis  at, 
or  subsequent  to,  the 
operation  is  made  to 
counteract  this  tenden- 
cy ;  but  frequently, 
however,  without  suc- 
.  [fthe  foot-stump 
be  confined  in  a  flexed 


Fig.  394. — Outer  aspect. 


Fig.  395. — Dorsal  aspect. 


position  during  the  healing,  and  for  a  time  afterward,  there  is  less 
danger  of  its  becoming  extended.     This  operation  can  aot  bo  rccom- 


264 


OPERATIVE   SURGERY. 


mended  as  a  substitute  for  those  that  are  to  follow,  in  point  of  com- 
fort and  usefulness.  Better  execution  is  done  with  an  artificial  limb- 
appliance  after  the  Syme's 
amputation  than  after  this 
operation. 
~jp/  Results. — The  mortali- 

-'  f  ty  is  about  eight  per  cent. 

Forbes'  Modification. — 
This  is  made  through  the 
same  incisions  as  Chopart's. 
After  the  cuneiform  bones 
have  been  separated  from 
the  scaphoid,  the  cuboid  is 
sawn  through  on  a  line  with 
them.      Inasmuch  as   this 


Fig.  396. — Removing  the  foot. 


Fig.  397. — Appearance  of  stump. 


operation  offers  no  additional  power  of  flexion  by  reason  of  its  muscu- 
lar attachments,  its  stump  may  become  subjected  to  the  same  annoy- 
ance as  the  former. 

In  this,  as  in  the  medio-tarsal  amputation,  the  after-treatment  ex- 
ercises a  most  important 
influence  upon  the  results. 
Sub-astragaloid  Disar- 
ticulation (De  Lignerolles). 
— Make  two  lateral  flaps  by 
an  incision  beginning  im- 
mediately above  the  tuber- 
osity of  the  os  calcis  on  the 
outer  side,  which  divides 
the  tendo  Achillis,  and  is 
carried  along  the  outer  side 


Fig.  398. — External  incision. 


AMPUTATIONS   OF  THE   LOWER   EXTREMITY. 


265 


of  the  os  calcis  in  a  curved  manner,  convexity  downward,  below  the 
external  malleolus,  thence  extending  obliquely  upward  across  the  mid- 
dle of  the  cuboid  to  the  dorsum  of  the  foot  (Fig.  398)  ;  then  vertically 
downward  across  the  inner  border  of  the  scaphoid  (Fig.  399)  till  it 
reaches  the  center  of  the  sole  of  the  foot ;  it  is  then  turned  directly 
backward  at  a  right  an- 
gle with  the  preceding 
cut,  and  joins  the  begin- 
ning of  the  incision  at 
the  inner  border  of  the 
tendo  Achillis  (Fig.  400). 
Dissect  up  both  flaps 
till  the  lateral  surface  of 
the  os  calcis  and  the  talo- 
scaphoid  joints  are  ex- 
posed, being  careful  not 
to  injure  the  tibio-tarsal 
joint ;  remove  the  bones 

in  front  of  the  medio-tarsal  junction  ;  seize  the  anterior  extremity  of 
the  os  calcis  with  bone-forceps,  depress  and  turn  it  inward,  and  divide 
the  external  lateral  ligaments  with  a  narrow  knife  about  a  third  of 
an  inch  below  the  tip  of  the  malleolus ;  then  divide  the  interosseous 


Fig.  399. — Internal  incision. 


Fig.  400. — Plantar  incision. 


FlO.  101. — Internal  ligaments. 


ligament  between  the  os  calcis  and  astragalus  ;  finally,  the  talo-calcane- 
an  ligament  is  divided  an  inch  below  the  internal  malleolus  (Fig.  1"! ). 
The  os  calcis  is  then  removed  (Fig.  402),  and  the  flap  united  in  its 
proper  position.    Fig.  403  shows  the  appearance  of  the  stump  after 

union  of  the  flaps. 


266 


OPERATIVE   SURGERY. 


Fig.  402. — The  bones  separated. 


Results.— Oxer  twelve  per  cent  are  reported  to  have  died  from  the 

operation  alone. 

Hancock's    Amputation. — This 

may  be  considered  a  combination 
of  the  sub-astragaloid  and  Piro- 
goffs  method.  The  operation  can 
be  done  through  incisions  similar 
to  the  latter  ;  the  flaps,  however, 
should  be  made  somewhat  longer. 
Saw  the  os  calcis  as  in  Pirogoffs 
method.  Make  a  transverse  sec- 
tion of  the  astragalus  (Fig.  402)  ; 
remove  it,  together  with  the  asso- 
ciated fragment  of  the  os  calcis, 
and  bring  the  sawn  surfaces  of  the 
remaining  portions  of  the  os  calcis  in  contact  with  the  under  surface 
of  the  articulated  portion  of  the  astragalus. 

Tripier's  Method. — By  this  method  it  is  thought 
possible  to  prevent  the  retraction  of  the  flap  and 
extension  of  the  stump  by  the  powerful  muscles 
attached  to  the  heel.  The  os  calcis  is  divided  on 
a  level  with  the  sustentaculum  tali  and  at  a  right 
angle  with  the  long  axis  of  the  tibia,  which  makes 
the  cut  surface  of  the  bone  parallel  with  the 
ground. 

Operation. — Begin  the  incision  of  the  soft 
parts  at  the  outer  border  of  the  tendo  Achillis,  on 
a  level  with  the  outer  malleolus,  carry  it  along  the 
outer  border  of  the  foot  to  the  base  of  the  meta- 
tarsal bone  of  the  little  toe,  thence  directly  across 
the  dorsum  of  the  foot  to  the  base  of  the  metatar- 
sal bone  of  the  great  toe ;  from  this,  it  passes 
across  the  sole  of  the  foot,  forming  a  convex  flap 
at  least  one  inch  longer  than  the  dorsal  one,  join- 
ing the  outer  incision  at  an  oblique  angle.  The  flaps  are  dissected  up 
sufficiently  to  admit  of  the  disarticulation  of  the  astragalo-scaphoid 
joint  and  the  horizontal  section  of  the  os  calcis  just  below  the  susten- 
taculum tali.  If  the  bone  be  divided  from  without  inward,  the  pos- 
terior tibial  artery  is  less  likely  to  be  injured.  The  wound  is  drained, 
and  the  flaps  united  and  surrounded  by  antiseptic  dressing. 

The  results  from  some  sources,  in  all  forms  of  amputation  through 
the  foot,  show  a  death-rate  of  about  twenty-three  per  cent.  How- 
ever, in  this  respect,  the  records  of  American  surgery  in  these  opera- 
tions are  but  little  in  excess  of  ten  per  cent. 

Irregular  Tarsal  Amputations  (Molliere).—  In  view  of  the  great  ad- 


Fig.  403. — Appear- 
ance of  stump. 


AMPUTATIONS   OF   THE   LOWER   EXTREMITY. 


267 


vantages  to  be  gained  by  a  strict  use  of  antiseptic  measures,  in  pro- 
moting union  by  first  intention,  limiting  suppuration,  and  lessening 
the  danger  of  necrosis,  it  is  suggested  that  amputations  across  the 
foot  be  made  irrespective  of  the  articulations  of  the  tarsal  bones  ;  in 
other  words,  that  the  foot  be  treated  as  if  it  contained  but  one  bone. 
Heretofore,  such  measures  have  been  followed  frequently  by  necrosis 
of  the  fractional  portions  of  the  tarsal  bones  remaining  in  the  stump. 
Amputation  at  the  Ankle — Removal  of  the  Entire  Foot  (Syme). — 
This  may  be  considered  one  of  the  most  practical  of  the  operations  on 
the  foot  and  ankle.  It  is  followed  not  only  by  a  low  rate  of  mortality, 
but  also  by  a  most  servicea- 
ble stump,  either  with  or 
without  an  artificial  appli- 
ance. The  patient  is  placed 
upon  a  table,  with  the  leg 
overhanging  it ;  the  thigh 
raised  by  an  assistant,  who 
at  the  same  time  flexes  the 
condemned  foot  upon  the 
leg,  by  seizing  and  pulling 
upward  on  its  anterior  por- 
tion. The  outlines  of  the 
respective  flaps  should  now 
be  carefully  drawn  before 

the  incisions  are  commenced.  The  line  indicating  the  proper  course 
of  the  plantar  incision  begins  at  the  apex  of  the  external  malleolus — 
for  left  side — and,  with  a  slight  backward  inclination,  passes  around 

the  foot  (Fig.  404)  to  a 
point  opposite  to  its  begin- 
ning, which  is  about  a  fin- 
ger's breadth  below  the 
apex  of  the  internal  malle- 
olus (Fig.  405). 

The  second  or  dorsal 
line  is  drawn  directly 
across  the  instep,  and  con- 
nects the  extremities  of  the 
plantar  incision. 

Operation. — The  sur- 
geon selects  a  scalpel  of 
large  size  and  with  a  strong  shank,  and  inserts  the  point  at  the  com- 
mencement of  the  incision  down  to  the  hone  at  a  right  angle  to  its 
outer  surface,  with  the  edge  undermost;  carries  it  along  the  gniding 
line  in  contact  with  the  bone  to  its  inner  extremity  ;  places  the  An- 
on the  heel  and  the  thumb  within  the  cut,  and  draws   Brmly 


Fig.  404. — Outer  incision. 


Via.  405. — Inner  incision. 


268 


OPERATIVE   SURGERY. 


backward  on  the  posterior  flap,  at  the  same  time  liberating  it  from 
the  outer  surface  and  sides  of  the  os  calcis,  back  to  near  the  insertion 
of  the  tendo  Achillis.  An  incision  is  now  made  down  to  the  bone  on 
the  anterior  line,  and  the  joint  opened  in  front;  the  foot  well  ex- 
tended, lateral  ligaments  divided,  and  foot  removed  by  liberating  the 
remaining  tissues  attached  to  the  posterior  surface  of  the  os  calcis,  in- 
cluding the  tendo  Achillis ;  always  remembering  to  closely  hug  the 
bone,  else  the  flap  may  be  perforated  and  its  integrity  impaired.    After 

the  removal  of  the  foot, 
dissect  up  the  soft  parts 
around  the  malleoli  a  suf- 
ficient distance  to  permit 
the  articular  ends  of  the 
bones  to  be  sawn  off  (Figs. 
406  and  407)  ;  cut  off  the 
extremities  of  the  tendons 
even  with  the  cut  surface  of  the  soft  parts,  bring  the  flap  into  position, 
unite  it  in  front  (Fig.  408),  and  dress  with  antiseptic  precautions. 


Fig.  406. — Bones  of  leg  sawn  through. 


Fig.  40*7.— Heel  flap. 


Fig.  408.— Flaps  united.         Fig.  4C9. — Side  view. 


Modifications.— Sawing  the  malleoli  obliquely  (Fig.  410)— instead  of 
removing  them  together  with  a  thin  transverse  section,. that  includes 
the  articular  surface  of  the  tibia,  as  recommended  by  Mr.  Syme— is  a 
modification  which  has  been  long  and  somewhat  extensively  practiced. 
It  is  believed  to  give  a  better-shaped  stump,  and  to  be  attended  with 


AMPUTATIONS  OF  THE  LOWER  EXTREMITY. 


269 


less  danger  to  life,  than  if  the  bony  canals  of  the  tibia  be  extensively 
opened,  as  in  the  case  of  transverse  section. 

Many  surgeons,  after  making  the 
plantar  incision,  open  the  joint  in  front, 
as  before  described,  disarticulate,  and 
dissect  the  heel-flap  from  behind  for- 
ward. 

This  affords  more  room  and  leverage 
to  aid  in  the  removal  of  this  flap,  but 
increases  the  danger  of  cutting  it.  The 
removal  of  the  periosteum  from  the 
sides  and  the  posterior  surface  of  the 
os  calcis,  including  the  insertion  of  the 
tendo  Achillis,  has  been  practiced.  If 
it  can  be  done  without  too  much  lacer- 
ation of  its  structure,  it  is  a  commend- 
able modification. 

By  some,  the  articular  cartilage  re- 
maining on  the  extremity  of  the  tibia  is 
scraped  off ;  this  procedure  is  thought 
to  hasten  the  healing  process.  Many 
methods,  adapted  to  various  forms  of 
injury  to  the  soft  parts,  have  been  de- 
vised to  modify  the  construction  of  the 
flaps  to  cover  the  end  of  the  stump. 
When  the  heel-flap  is  impossible,  tissues 
can  be  taken  from  all  or  either  of  the 
three  remaining  aspects  of  the  foot  to 

supply  it ;  being  ever  cautious  to  avoid  injuring  the  posterior  tibial 
artery,  as  it  lies  below  the  inner  malleolus. 

Fallacies. — The  incision  across  the  instep  lies  below  the  line  of 
articulation  between  the  astragalus  and  the  tibia  ;  therefore,  unless 
care  be  taken  to  locate  the  joint,  the  operator  will  cut  down  upon  the 
neck  of  the  astragalus,  and,  not  finding  the  joint,  will  become  much 
confused  ;  or  he  may  even  open  the  articulation  between  the  scaphoid 
and  astragalus.  If  the  plantar  flap  be  made  too  long,  it  will  be  im- 
possible to  carry  it  over  the  point  of  the  heel  ;  therefore,  if  it  be  neces- 
sary to  make  a  long  heel-flap,  the  joint  should  be  opened  at  once 
from  before  backward,  and  the  heel-flap  dissected  off  from  above 
down  ward. 

Results.— The  rate  of  mortality  from  Syme's  operation  is  from 
five  to  nine  per  cent. 

Roux's  Operation.— Begin  the  incision  at  the  outer  side  of  the 
tendo  Achillis,  a  little  above  the  insertion  ;  carry  it  straight  forward 
beneatb   the  outer  malleolus  (Fig.  411),  then  in  a  curved   line  across 


Fig.  410. 


-Oblique  division  of 
malleoli. 


270 


OPERATIVE   SURGERY. 


the  instep  half  an  inch  in  front  of  the  articular  edge  of  the  tibia  back- 
ward and  downward,  in  front  of  the  inner  malleolus,  to  the  sole 
(Fig.  412)  ;  then  obliquely  backward  to  near  its  outer  border ;  then 


Fig.  411. — Outer  incision. 


Fig.  412. — Inner  incision. 


backward  and  upward  over  the  heel  to  the  point  of  beginning.  Dis- 
sect up  the  edges  of  the  flaps,  open  the  joint  at  the  outer  side,  and 
complete  the  internal  flap  after  disarticulation  of  the  foot.  The  bones 
should  then  be  divided,  as  in  Syme's  method  ;  flaps  united  and  dressed 
antiseptically. 

Pirogoff's  Amputation. — This  is  osteo-plastic  in  character,  and  con- 
sists in  the  application  of  the  sawn  surfaces  of  the  posterior  portion 
of  the  os  calcis  (Fig.  416)  to  the  sawn  surfaces  of  the  bones  of  the  leg. 
The  length  of  the  limb  is  well  preserved,  and,  without  the  use  of  an 

artificial  appliance,  the 
stump  is  often  superior  to 
that  of  Syme's  operation. 
Operation. — Flex  the 
foot  at  a  right  angle  with 
the  leg  ;  make  an  incision 
down  upon  the  bone,  from 
the  tip  of  the  internal 
malleolus  directly  across 
the  sole,  its  lowermost 
portion  being  a  little  in 
front  of  the  long  axis  of 
the  tibia  (Fig.  413), 
around  the  foot  to  a  point 
in  front  of  the  apex  of 
the  external  malleolus 
(Fig.  414). 

The  extremities  of 
this  are  connected  by 
another  carried  down  to 
the  bone,  half  an  inch  in 
front  of  the  lower  extrem- 
ity of  the  tibia.  Open 
the   joint  in  front,  divide  the  lateral  ligaments,  disarticulate  the 


Fig.  414. — Outer  incision. 


AMPUTATIONS   OF   THE   LOWER   EXTREMITY. 


271 


head  of  the  astragalus  (Fig.  415),  and  with  a  narrow  saw  divide  the 

os  calcis  obliquely  downward  and 
forward  in  the  line  of  the  plantar 
incision.  Eaise  the  anterior  flap, 
dissect  up  the  tissues  around  the 
lower  ends  of  the  bones,  and  saw 


Fig.  415. — Separating  articular  surfaces.  Fig.  416. — Lines  of  section  of  os  calcis. 


through  the  lower  extremities  of  the  tibia  and  fibula,  just  above  their 
articular  surfaces.  If  any  of  the  divided  tendons  be  below  the  edge 
of  the  wound,  cut  them  off  on  a  level  with  it. 

The  cut  surface  of  the  os  calcis  is  then  brought  forward  and  placed 
in  contact  with  that  of  the  tibia ;  the  wound  united  and  dressed  anti- 
septically. 

Fallacies. — If  the  posterior  border  of  the  os  calcis  be  cut  too  long, 
the  divided  bone  surfaces  can  not  be  properly 
apposed  without  force  which  will  cause  the 
fragment  to  tilt  backward.  This  can  be  reme- 
died by  removing  more  bone  from  this  border, 
or  by  dividing  the  tendo  Achillis.  Whenever 
this  tendon  inclines  to  tilt  the  bone,  it  should 
be  divided.  The  fragment  can  be  united  to 
the  tibia  by  silver  wire  to  retain  the  sawn  sur- 
faces in  apposition.  The  os  calcis  has  been 
sawn  at  different  angles  to  that  bone  (Fig.  41G), 
but  the  one  just  considered  has  given  the  most 
satisfactory  results.  Fig.  417  shows  the  ap- 
pearance of  the  stump  after  Pirogoff's  operation. 

Results. — The  death-rate  from  this  opera- 
tion ig about  ten  percent. 

Modifications  of  Pirogoff's  Operation. — 
Fergusson's  modification  consists  in  not  remov- 
ing the  malleoli,  unless  they  are  diseased,  but 
in  dividing  the  tendo  Achillis,  and  placing  the 


I 


Fig.  417. — Appearance  of 
stump. 


272 


OPERATIVE   SURGERY. 


sawn  end  of  the  os  calcis  between  them.     Dr.  Turnipseed  and  others 
have  practiced  this  modification  and  recommend  it. 

Le  Fort's  Modification.— The  incisions  for  the  flaps  are  similar  to 
those  in  Eoux's  modification  of  Syme's  amputation.  The  ankle-joint 
is  exposed  by  raising  the  dorsal  flap,  keeping  close  to  the  bone  so  as 
not  to  injure  the  posterior  tibial  artery.  Divide  the  external  lateral 
ligament,  and  the  ligaments  between  the  astragalus  and  os  calcis. 
Turn  the  foot  inward,  and  remove  the  anterior  portion  of  the  foot  at 
the  medio-tarsal  joint.  Seize  the  astragalus  with  strong  forceps,  make 
tense  the  ligaments  connecting  it  with  the  bones  above,  which  should 
then  be  cut  and  the  bone  removed.  Push  down  the  os  calcis,  and 
with  a  narrow  saw  remove  its  upper  third 
from  behind  forward,  beginning  just 
above  the  insertion  of  the  tendo  Achillis. 
Saw  off  the  malleoli  and  the  articular 
surface  of  the  tibia,  as  in  Pirogoff's  opera- 


Fig.  418. — Sawn  bones  in  Le  Fort's  method. 


Fig.  419.  — Appearance  of  stump  in 
Le  Fort. 


tion  (Fig.  418)  ;  place  the  sawn  surfaces  in  apposition,  and  dress  in 
the  usual  manner.     This  modification  permits  the  reserved  fragment 

of  the  os  calcis,  when  placed  in 
position,  to  maintain  the  same  rel- 
ative axis  to  the  end  of  the  stump 
that  it  held  to  the  foot ;  conse- 
quently the  direct  pressure  is  re- 
ceived upon  the  integumentary 
covering  already  adapted  to  the 
purpose  (Fig.  419). 

Bruns  recommended  that  the 
sawn  surfaces  of  the  os  calcis  be 
made  concave,  and  the  tibia  con- 
Fig.  420. — Bruns'  modification.  vex  (Fig.  420). 


AMPUTATIONS  OF  THE  LOWER  EXTREMITY. 


273 


Fig.  421. — Outer  incision. 


EsmarcJrs  Modification  of  Le  Fort's  operation  consists  of  two  in- 
cisions :  one  across  the  sole,  the  other  across  the  dorsum  of  the  foot. 
The  former  commences  about  four  fifths  of  an  inch  below  the  tip  of 
the  external  malleolus, 
and  with  the  convexity 
forward  (Fig.  421),  runs 
under  the  cuboid  and 
scaphoid  bones  (Fig. 
422).  ending  at  the  inner 
side,  one  inch  below  and 
in  front  of  the  internal 
malleolus  (Fig.  423). 
The  curved  dorsal  incis- 
ion (Fig.  424),  with  its 
concavity  forward  to  the 
tuberosity  of  the  scaph- 
oid, connects  the  ex- 
tremes of  the  plantar  one. 
Dissect  up  the  dorsal  flap 
to  the  tibio-tarsal  joint, 
which  should  be  opened, 
the  foot  bent  downward, 
and  the  upper  surface  of 
the  os  calcis  exposed  suf- 
ficiently to  apply  a  small  saw  behind  the  upper  margin  of  the  tuber- 
osity of  the  os  calcis  and  the  bone  sawn,  as  before  described  (Fig.  418). 

The  flaps  are  then 
united,  drained,  and 
dressed  antiseptically. 
Osteoplastic  Am- 
putation of  Heel  and 
Ankle  (Mikulicz). — 
This  operation  is  spe- 
cially indicated  in 
cases  in  which  the  tis- 
sues composing  the 
posterior  part  of  the 
foot  have  been  de- 
stroyed. 

Operation. — Select 
a  strong  scalpel  and 
make  an  incision  from 
just  in  front  of  the 
tubercle  of  the  scaph- 
oid directly  across  the 


Fig.  422. — Plantar  incision. 


Fio.  1-). — Dorsal  incision. 


18 


274 


OPERATIVE   SURGERY. 


sole  of  the  foot,  down  to  the  bone,  terminating  just  behind  the  base  of 
the  fifth  metatarsal  bone.  From  each  extremity  of  the  plantar  incis- 
ion, one  is  carried  upward  and  backward  to  the  bone  of  the  corre- 
sponding malleolus,  and  the  upper  extremities  of  these  incisions  are 
connected  by  a  fourth,  passing  directly  transversely  behind  the  limb 
and  carried  through  the  tendo  Achillis.  The  lateral  ligaments  of  the 
joint  are  divided,  the  joint  opened  from  behind,  and  the  calcaneum 
and  the  astragalus  are  carefully  dissected  out  and  removed  by  disar- 
ticulation at  the  medio-tarsal  joint.  The  malleoli,  including  the 
articular  surface  of  the  tibia,  are  sawn  off  transversely,  and  also  the 
cuboid  and  scaphoid  bones  are  sawn  transversely  through  on  a  line 
corresponding  to  the  middle  of  the  latter  bone.  The  sawn  surfaces  of 
bone  are  then  placed  in  contact  with  each  other,  and  wired  or  pegged 
in  position. 

AMPUTATIONS   OF   THE   LEG. 

Supra-malleolar  Amputation. — This  operation  resembles  more  near- 
ly a  Syme,  in  location,  than  any  other  that  can  be  performed  upon  the 
leg  ;  but,  owing  to  the  comparatively  high  rate  of  mortality  resulting, 
it  is  not  to  be  recommended  in  preference  to  a  higher  amputation. 
The  flaps  must  always  be  made  from  the  firmest  and  best-nourished 
tissues  accessible. 

Operation. — Two  semilunar  incisions,  one  external  and  one  inter- 
nal, are  made,  each  beginning  posteriorly  at  the  posterior  border  of 
the  malleoli,  and  passing  forward  beneath  them,  then  around  upon  the 
dorsum  of  the  foot,  an  inch  in  front  of  the  ankle-joint,  where  they 
join  each  other.  Their  posterior  extremities  are  then  united  by  a 
curved  transverse  incision,  with  the  convexity  downward.  The  flaps 
are  dissected  upward,  and  the  bones  of  the  leg  divided  transversely 
about  an  inch  above  the  articular  surfaces. 

Amputation  of  the  Leg  at  the  Lower  Third. — When  possible,  the 
leg  must  always  be  amputated  at  this  situation.  It  gives  a  long  ful- 
crumage  for  an  artificial  limb,  and  admits  of  the  formation  of  a  sym- 
metrically tapering  stump,  which  can  be  closely  adjusted  to  the  socket 
of  the  artificial  appliance. 

Three  methods  can  be  employed  :  the  circular,  the  bilateral,  and 
the  hood  flaps,  embracing  only  the  integument  and  subcutaneous  tis- 
sues, or  combined  with  the  periosteum  covering  the  subcutaneous  sur- 
face of  the  tibia. 

Circular  Method  with  Periosteal  Reflection.— If  the  situation  can 
be  selected  for  the  site  of  the  operation,  it  should  be  three  or  three 
inches  and  a  half  from  the  lower  extremity  of  the  tibia;  or,  more 
definitely,  at  the  point  where  the  tapering  of  the  limb  from  above 
downward  ceases.  The  length  of  the  flap  should  be  equal  to  a  fourth 
of  the  circumference  of  the  limb  at  the  proposed  point  of  section. 

Operation.—  Prepare  the  patient  in  the  usual  manner ;  make  a  cir- 


AMPUTATIONS  OF  THE  LOWER  EXTREMITY. 


275 


cular  incision  through  the  integument  and  subcutaneous  tissue  down 
to  the  muscular  fascia  and  the  subcutaneous  surface  of  the  tibia. 
Dissect  the  sleeve  for  about  an  inch  all  around,  then  divide  the  perios- 
teum on  the  subcutaneous  surface  of  the  tibia,  by  a  transverse  incis- 
ion at  the  point  of  reflection  of  the  flap  ;  divide  it  also  longitudi- 
nally at  the  outer  and  inner  borders  of  the  surface  of  the  tibia  a  suffi- 
cient distance — one  fourth  of  an  inch — to  allow  the  periosteum  to  be 
reflected  upward  wThile  attached  to  the  inner  surface  of  the  flap. 
These  longitudinal  incisions  are  repeated  as  often  as  it  becomes  neces- 
sary to  detach  the  periosteum  and  keep  pace  with  the  turning  up  of 
the  flap  at  the  remaining  portions  of  its  circumference.  That  is,  in- 
stead of  dissecting  the  flap  from  the  tibia,  its  periosteum  is  detached 
from  its  subcutaneous  surface,  and  pushed  up  to  the  point  of  proposed 
section  while  still  adherent  to,  and  forming  a  limited  lining  to  the 
flap.     Fig.  425  shows  the  extent  of  the  reflection  of  the  periosteum, 

which,  however,  in  the  operation,  remains 
attached  to  the  inner  surface  of  the  corre- 
sponding portion  of  the  flap.  The  tibia 
is  sawn  carefully  through  at  the  highest 
point  of  the  periosteal  reflection,  the  fibula 


Line  indicating  antero-posterior 
coaptation  of  flaps. 

Line  indicating  direction  of  sub- 
cutaneous surface  of  tibia. 


Line  indicating1  oblique  coapta- 
tion of  flaps. 

Fig.  425. — Reflection  of  the  peri- 
osteum. 


Fig.  426. — Oblique  coaptation. 


exposed  one  fourth  of  an  inch  higher  and  divided  separately  by  sawing 
toward  the  tibia.  The  flaps  are  then  united  obliquely,  so  that  not 
only  will  the  line  of  union  fall  between  the  two  bones,  but  that — which 
is  more  important — the  periosteal  lining  of  the  inner  portion  of  the 
flap  will  fall  and  Lie  smoothly  across  the  divided  extremity  of  the 
tibia,  Bince  lie  subcutaneous  surface  of  the  tibia  lies  parallel  with  the 
line  of  oblique  coaptation  (Fig.  420).     It  will  be  necessary,  in  order 


276 


OPERATIVE   SURGERY. 


to    reflect  the   sleeve-flap,    that  it  be  divided  longitudinally;   this 
is  done  at  such  a  point  as  will  become  lowermost  when  the  flaps  are 
obliquely  joined.    The  limb  should  be  dressed  antiseptically,  using  cau- 
tion to  maintain  the  oblique  direction  of  the 
flaps  till  the  healing  process  is  complete.       _  \ 

The  periosteal  flap  grows  to  the  end  of  the 
bone,  preventing  it  from  becoming  atro- 
phied, and  likewise  preventing  the  adhesion 


Periosteum  on 
subcutaneous 
surface  of  tibia. 


Tibia. 


Cicatrix. 


Fig.  427. — Dissected  specimen  showing  the  relation 
of  parts. 


Fig.  428.— Bilateral  flaps. 


of  the  cicatrix  to  the  end  of  the  tibia.  Fig.  427  shows  a  longitudinal 
section  through  the  flap  three  months  after  this  operation  had  been 
done. 

Results. — Of  the  eight  cases  done  by  myself  all  have  resulted  in  ex- 
ceptionally serviceable  stumps.  In  no  instance  have  bony  spiculas  ap- 
peared, and  in  each  the  stump  has  given  entire  satisfaction  to  the 
patient. 

The  Bilateral  Flap  Method  (Fig.  428,  a)  consists  of  equilateral 
flaps  constructed  from  the  integument  and  subcutaneous  tissue  at  the 
outer  and  inner  surface  of  the  limb.  The  operation  may  be  performed 
by  this  method  either  with  or  without  the  periosteal  lining.  The  cir- 
cular, with  oblique  coaptation,  is  by  far  the  better  method  if  the  peri- 
osteum be  raised  ;  since  in  antero-posterior  coaptation,  the  periosteal 
flap  will  be  tilted,  and  become  more  liable  to  eversion  and  the  produc- 
tion of  bony  spicular  growths. 


AMPUTATIONS   OF   THE   LOWER   EXTREMITY.  277 

The  bilateral  flaps  are  made  by  first  ascertaining  the  circumfer- 
ence of  the  limb  at  the  point  of  the  proposed  amputation.  The  base 
of  each  flap  is  then  made  equal  to  half,  and  the  length  to  one  fourth 
of  this  circumference.  Each  one  is  nearly  semicircular,  and  their 
points  of  junction  should  be  at  the  center  of  the  limb,  anteriorly  and 
posteriorly,  which  will  bring  the  anterior  point  of  union  to  the  inner 
side  of  the  crest  of  the  tibia  ;  it  should  also  be  a  little  below  the  point 
of  the  proposed  section  of  the  tibia.  The  posterior  point  of  junction 
is  made  above  that  of  the  anterior,  to  provide  for  suitable  drainage 
(Fig.  4:28,  a).  When  properly  outlined,  each  flap  is  dissected  upward 
to  near  the  point  where  the  bone  is  to  be  divided  ;  the  muscles  are 
divided  by  a  circular  incision,  then  pushed  upward  above  the  anterior 
point  of  union  of  the  flaps,  and  the  bones  sawn  off — the  fibula  a  fourth 
of  an  inch  the  shorter — on  a  line  corresponding  to  the  junction  of  the 
flaps  posteriorly.  If  there  be  an  undue  amount  of  muscular  tissue  be- 
hind, it  can  be  trimmed  off  until  it  admits  of  the  ready  union  of  the 
divided  borders  of  the  flaps.  Suitable  drainage,  antero-posterior  co- 
aptation, and  an  antiseptic  dressing,  comprise  the  immediate  atten- 
tion to  the  case. 

The  Hood,  or  Oval  Flap  Method  is  a  modification  of  the  circular, 
the  skin-cuff  being  slit  up  posteriorly  to  the  point  at  which  the  bone 
is  to  be  divided,  and  the  corners  trimmed  off  to  resemble  the  outlines 
of  the  lower  portions  of  the  bilateral  flap.  This  flap  is  then  reflected 
upward,  and  the  muscles  and  bones  divided  as  before.  The  line  of 
union  is  made  antero-posteriorly. 

The  advantages  claimed  for  this  method  are  :  its  perfect  drainage  ; 
the  location  of  the  cicatrix  on  the  posterior  surface  ;  and  the  carrying 
of  the  integument  over  the  end  of  the  bone,  thus  preventing  the  adhe- 
sion of  the  cicatrix  to  it.  Like  the  bilateral,  it  can  be  employed  in  con- 
nection with  the  periosteal  flap  ;  still,  as  it  is  joined  to  form  an  antero- 
posterior line  of  union,  it  is  open  to  the  same  objections  as  the  former 
with  reference  to  the  periosteum. 

Result*. — The  rate  of  mortality  from  amputation  in  the  lower  third 
is  variously  estimated  at  from  thirteen  to  twenty-two  per  cent  ;  this 
being,  however,  less  than  at  any  other  part  of  the  limb. 

Amputation  through  the  Middle  Third. — The  limb  can  be  ampu- 
tated at  this  point  by  the  same  methods  employed  at  the  lower  third 
of  the  leg.  The  principles  applicable  to  the  lower  third  have  an  equal 
force  nt  thiB  situation.  The  presence  of  the  calf  offers  an  additional 
difficulty  in  obtaining  the  oblique  coaptation,  but  does  not  interpose 
an  insurmountable  obstacle  to  it.  Care  in  dressing  the  stump  will 
maintain  the  obliquity  of  the  line  of  coaptation  in  the  periosteal  flap 
method.  Tin'  bilateral  and  hood  flap  methods,  either  with  or  without 
the  periosteal  lining,  present  to  the  surgeon  the  means  of  making  a 
most  serviceable  stump.     Jf  other  than  the  preceding  be  desired,  the 


27g  OPERATIVE   SUKGERY. 

long  external  and  short  internal  flaps  are  to  be  preferred,  instead  of 
either  the  long  anterior  or  the  long  posterior,  since  either  of  these  im- 
pede drainage,  and  both  by  their  weight  exert  undue  traction  across 
the  crest  of  the  tibia. 

The  Unilateral  Flap  Method,  combined  with  a  semicircular  in- 
cision on  the  opposite  side,  offers  good 
drainage,  and  carries  the  cicatrix  be- 
yond the  point  of  pressure. 

These  flaps  may  be  muscular  or  in- 
J       v      \  tegumentary ;  the  former  are  made  by 

transfixion,  the  latter  by  external  in- 
cision with  the  ordinary  scalpel,  and 
circular  section  of  the  muscles  with 
the  long  knife.  The  principles  con- 
trolling the  length  of  the  flaps  are  the 
same  as  previously  stated.  The  long 
flap  should  be  made  from  the  outer 
side  of  the  leg,  having  a  base  some- 
what less  than  one  half  the  circumfer- 
Fig.  429.— Long  external  flap.        ence  of  the  limb.     The  inner,  or  short 

flap,  is  semicircular  in  shape  (Fig.  429). 
The  bones  are  sawn  off  just  above  the  anterior  point  of  junction  of  the 
flaps,  which  are  then  to  be  united,  and  the  wound  dressed  as  before. 

Results. — The  rate  of  mortality  of  amputations  in  this  portion 
of  the  limb  is  about  twenty-seven  per  cent. 

Amputation  at  the  Upper  Third. — Either  of  the  methods  em- 
ployed in  the  middle  third  is  applicable  at  this  situation.  The  fibula 
should  not  be  removed,  as  the  superior  tibio-fibular  articulation  some- 
times communicates  with  the  knee-joint.  The  tibia  is  sawn  below  the 
insertion  of  the  ligamentum  patellae. 

Results. — The  mortality  is  about  forty-three  per  cent. 
Amputation  at  the  Knee-Joint  (Disarticulation). — The  bilateral, 
the  circular,  the  long  anterior,  and  the  hood  flaps  are  the  ones  best 
constituted  to  meet  the  indications.  The  stump  resulting  from  either 
has  an  early  sustaining  power  with  a  broad  point  of  support,  which, 
however,  later  in  life  becomes  somewhat  lessened  in  size.  The  joint 
surface  is  not  to  be  molested  in  any  other  way  than  by  scraping  off 
the  articular  cartilage. 

The  patella,  unless  diseased,  should  be  allowed  to  remain.  It  will 
be  found  to  rest  just  above  the  condyles,  where  it  affords  a  good  point 
of  attachment  for  the  quadriceps  extensor.  The  ligaments  should  be 
divided  close  to  the  femur,  the  semilunar  cartilages  remaining  attached 
to  the  tibia.  The  popliteal  artery  is  tied,  only  after  sufficient  isolation 
to  admit  of  the  application  of  the  ligature  above  the  articular  branch- 
es.    The  popliteal  vein  also  should  be  isolated  and  tied. 


AMPUTATIONS   OF   THE   LOWER   EXTREMITY.  279 

Bilateral  Method. — This,  without  doubt,  is  the  best  method.  It 
provides  two  well-nourished  flaps,  which,  when  united,  locate  -the 
cicatrix  between  the  condyles  posteriorly,  thereby  affording  admirable 
drainage. 

Operation. — With  the  thigh  elevated  and  the  leg  extended,  begin 
the  anterior  incision  of  either  flap,  one  inch  below  the  tuberosity  of 
the  tibia,  cutting  through  the  skin  and  subcutaneous  tissues  and  mus- 
cles. Carry  it  downward  and  forward  below  the  curve  of  the  leg, 
thence  inward  and  backward  to  the  middle  of  the  under  surface  of  the 
leg,  then  directly  upward  to  the  middle  of  the  popliteal  space  (Fig.  428, 
b).  The  opposite  flap  is  made  in  a  similar  manner  ;  remembering,  how- 
ever, that  the  flap  at  the  inner  side  must  be  made  the  longer,  on  ac- 
count of  the  greater  length  and  size  of  the  inner  condyle.  Kaise  the 
flaps  until  the  articulation  and  the  apex  of  the  patella  are  reached  ; 
divide  the  ligamentum  patellae  ;  open  the  joint  in  front ;  divide  the 
crucial  ligaments  ;  draw  the  head  of  the  tibia  forward,  and  pass  a  long 
knife  behind  it ;  extend  the  leg  somewhat  and  cut  the  remaining  tis- 
sues directly  downward.  Before  severing  these  tissues  be  careful  to 
ascertain  if  perfect  control  be  had  of  the  femoral  artery.  After  re- 
moval of  the  leg  the  flaps  present  the  appearance  shown  in  Fig. 
430.     The  flaps  are  united  and  suitable  drainage  provided.     A  not  in- 


Fig.  430. — Appearance  of  the  flaps.  Fig.  431. — Appearance  of  the  stump. 

frequent  sequel  to  this  operation  is  the  formation  of  an  abscess  beneath 
the  quadriceps  extensor,  due  to  the  collection  of  pus  at  the  upper  end 
of  the  synovial  pouch  of  the  joint ;  the  elevation  of  the  stump  causing 
it  to  gravitate  to  that  point.  This  can  be  avoided  by  the  division  of 
the  lateral  synovial  bands  commanding  the  entrance  to  it,  and  the  in- 
troduction of  a  drainage-tube  to  the  uppermost  portion  ;  or  by  carrying 
the  tube  through  the  uppermost  extremity  to  the  anterior  surface  of  the 
thigh.  Sometimes  compression  firmly  and  continuously  applied  over 
the  pouch  will  answer  the  purpose.  When  healed  the  stump  presents 
the  appearance  shown  in  Fig.  431.  If  care  be  not  taken  in  the  applica- 
tion of  the  dressings,  undue  pressure  will  be  made  on  the  tissues  cover- 
ing the  condyles  of  the  femur,  causing  ulceration  and  even  sloughing. 


280 


OPEKATIVE   SUEGERY. 


Fallacy.— It  has,  however,  one  fallacy,  which  has  been  the  cause 
of  much  chagrin  to  surgeons  on  rare  occasions— the  danger  of  mak- 
ing the  flaps  too  short,  followed  by  the  necessity  of  removing  the 
patella,  or  sawing  off  the  condyles  before  the  flaps  can  be  properly 
united.  If  the  semilunar  fibro-cartilages  be  permitted  to  remain  con- 
nected with  the  femur,  they  will  lessen  the  degree  of  retraction  of  the 
soft  parts ;  however,  when  thus  allowed  to  remain,  they  not  infre- 
quently slough  away. 

Circular  Method.— Extendi  the  leg  and  make  a  circular  incision 
around  it,  about  four  inches  below  the  patella,  through  the  integu- 
ment and  subcutaneous  tissues.  Dissect  it  up  to  the  edge  of  the  pa- 
tella ;  flex  the  leg  and  divide  the  ligamentum  patellae  at  its  apex ;  then 
open 'the  joint  in  front,  and  divide  the  lateral  ligaments  close  to  the 


Fig.  432. — Circular  flap  method. 

femur,  so  that  the  semilunar  cartilage  will  remain  connected  with  the 
tibia.  Flex  the  leg  and  cut  the  crucial  ligaments.  Pass  a  long  knife 
between  the  bones,  extend  the  leg,  and  sever  the  posterior  connections 
as  before  (Fig.  432).     The  flaps  can  be  united  from  before  backward 


Fig.  433. — Anterior-posterior  coaptation. 


Fig.  434. — Transverse  coaptation. 


(Fig.  433),  or  transversely  (Fig.  434),  the  former  being  the  better 
method,  for  obvious  reasons. 


AMPUTATIONS  OF  THE  LOWER  EXTREMITY. 


281 


Fig.  435. — Line  of  incisions. 


Long  Anterior,  with  a  Short  Posterior  Flap. — Flex  the  leg  and 
make  a  longitudinal  semicircular-shaped  flap,  beginning  a  little  below 
the  center  of  the  in- 
ner surface  of  the  inter- 
nal condyle,  extending 
around  in  front  five 
inches  below  the  pa- 
tella to  a  similar  point 
on  the  external  con- 
dyle (Fig.  435).  Dis- 
sect the  flap  upward 
to  the  patella,  open  the 
joint  as  before ;  draw 
the  head  of  the  tibia 
forward  and  pass  a  long 
knife  behind  it,  mak- 
ing the  short  posterior 
flap  from  above  down- 
ward, beginning  the 
incision  at  the  upper 
borders  of  the  anterior 
flap.  When  united  the 
cicatrix  is  well  protected  and  good  drainage  afforded  (Fig.  43G). 

Hood  Flap. — This  varies  but  little  from  the  bilateral ;  having  a 

somewhat  oval  outline  in 
front,  instead  of  a  retiring 
angle. 

Results.  —  The  rate  of 
mortality  from  amputation 
through  the  knee-joint  varies 
but  little  from  amputations 
of  the  lower  limb,  as  a  whole, 
averaging  in  the  latter  about 
thirty-four  per  cent ;  in  the 
former,  thirty-two  per  cent. 
Amputation  through  the 
knee-joint  offers,  as  a  rule,  a  better  chance  for  life  than  through  the 
upper  third  of  the  leg. 

Amputation  through  the  Condyles.— This  measure  possesses  no 
advantage  over  the  one  made  through  the  articulation.  The  rate 
of  mortality  is  somewhat  increased,  being  reported  at  about  forty- 
eight  per  cent,  although  this  would  be,  without  doubt,  much  less- 
ened by  the  employment  of  antiseptic  measures;  and  the  useful- 
ness of  the  stump  is  decidedly  in  favor  of  the  latter.  However, 
as  conditions  sometimes  arise  rendering  the  disarticulation   imprac- 


■WRfJSJ^v. 


Fig.  436. — Appearance  of  stump. 


282 


OPERATIVE   SURGERY. 


ticable,  amputation  through  the  condyles  becomes  a  valuable  expe- 
dient. 

Carden's  Amputation.— -Extend  the  leg,  seize  the  joint  with  the 
left  hand,  the  end  of  the  thumb  and  index-finger  resting  as  nearly  as 
possible  over  the  center  of  each  condyle.  With  a  stout  scalpel  make 
an  anterior  semilunar  flap,  commencing  at  the  point  indicated  by  the 
end  of  the  index-finger,  passing  around  in  front  about  two  inches  be- 


Fig.  437.— Garden's  method. 


Fig.  438.— Gritti's  and  Stokes'  method. 


low  the  patella  to  the  end  of  the  thumb  on  the  opposite  side.  If  the 
question  of  amputation  or  excision  be  undecided,  reflect  the  anterior 
flap  first ;  then,  if  the  condition  of  the  parts  require  amputation,  con- 
nect the  extremities  of  the  anterior  flap  by  a  short  posterior  one  car- 
ried directly  down  to  the  bone  (Fig.  437).  Reflect  both  flaps  upward 
to  the  base  of  the  condyles  ;  flex  the  leg  to  draw  down  the  patella,  and 
divide  the  remaining  tissues  surrounding  the  condyles  down  to  the 


AMPUTATIONS   OF   THE   LOWER   EXTREMITY.  283 

bone  ;  then  saw  off  the  condyles  at  their  base,  secure  the  vessels  as 
before  described,  and  unite  the  divided  parts. 

Results. — The  rate  of  mortality  as  reported  by  Garden  was  about 
seventeen  per  cent. 

Gritti's  Amputation  (Fig.  438,  a). — Extend  the  leg  and  make  a 
rectangular  flap,  extending  from  the  center  of  the  condyles  to  the  tu- 
berosity of  the  tibia.  Divide  the  ligamentum  patella?  at  its  insertion 
and  dissect  up  the  flap  containing  it.  Divide  the  integument  on  the 
posterior  surface  by  a  circular  incision.  Remove  the  synovial  mem- 
brane from  its  attachments  to  the  femur  in  front,  and  saw  the  bone 
just  above  the  articular  cartilages.  Introduce  a  long  knife  and  cut 
the  remaining  tissues  from  within  outward.  Saw  off  the  articular 
surface  of  the  patella.  Allow  the  anterior  flap  to  fall  into  position, 
causing  the  sawn  surface  of  the  patella  to  come  in  contact  with  the 
divided  end  of  the  femur.  This  operation  is  osteo-plastic  in  charac- 
ter, being  allied  to  Pirogoff's. 

Stokes'  Modification  of  Gritti's  method  consists  in  making  an  an- 
terior oval  instead  of  a  rectangular  flap — the  posterior  flaps  being 
made  one  third  its  length  ;  and  the  femur  is  sawn  off  an  inch  above 
the  condyles  (Fig.  438,  b),  instead  of  through  their  base.  The  car- 
tilaginous surface  of  the  patella  is  scraped  off,  and  it  is  then  united 
to  the  extremity  of  the  femur  by  strong  catgut  passed  through  the 
soft  tissues  immediately  behind  the  bone. 

Results. — The  rate  of  mortality  for  Gritti's  operation  and  Stokes' 
modification  is  reported  at  about  thirty  per  cent. 

Amputation  of  th.3  Thigh. — The  muscles  surrounding  the  thigh  are 
of  large  size  and  many  of  them  of  great  length.  Those  on  the  pos- 
terior and  many  on  the  anterior  surface  extend  from  the  pelvis  to  the 
leg.  On  the  inner  side  their  length  is  but  little  less  and  their  bulk  is 
increased. 

The  greater  the  length  of  a  muscle  from  its  origin  to  the  point  of 
division,  the  more  marked  will  be  its  retraction,  other  things  being 
equal.  It  therefore  happens,  in  amputation  of  the  thigh,  unless  care 
be  exercised  to  allow  for  the  greater  degree  of  contraction  of  the  long 
muscles,  that  the  bone  protrudes,  or  presses  too  strongly  against  the 
flap,  giving  it  an  undue  conicity,  or  otherwise  distorting  the  stump. 
The  position  in  which  the  limb  rests  during  the  healing  process  has  an 
influence  on  the  muscular  retraction.  For  instance,  if  the  limb  be 
extended  during  the  division  of  the  muscles,  the  posterior  ones,  on 
account  of  their  greater  length  and  tension,  retract  the  most,  and  if 
to  this  be  added  the  additional  retraction  due  to  placing  the  stump 
in  a  semi-fixed  position — on  a  pillow,  or  by  swinging— during  the  heal- 
ing process,  the  tendency  to  cause  tender,  painful,  and  otherwise 
troublesome  stump-  i-  increased.  To  avoid  this,  the  limb  should  be 
held  as  nearly  as  possible   at   the  same  angle  with  the  body,  when  the 


284 


OPERATIVE   SURGERY. 


muscles  are  being  divided,  as  that  in  which  it  will  be  placed  when  the 
dressing  is  completed  and  during  the  process  of  recovery. 

In  all  amputations  of  the  thigh  an  ante- 
rior rectangular,  or  oval  periosteal  flap  should 
be  made,  its  outer  surface  remaining  associ- 
ated with  the  tissues  connected  with  or  spring- 
ing from  it  (Fig.  439,  a).  If  an  amputation 
be  made  close  to  the  band  of  a  tourniquet 
or  the  elastic  bandage  of  Esmarch,  the  mus- 
cles will  be  held  too  firmly  to  admit  of  the 
natural  retraction  until  after  the  bone  is  sawn 
and  they  are  liberated  ;  this  is  a  fault  which 
must  be  recognized  and  corrected  by  cutting 
the  muscles  lower  than  would  otherwise  be 
done. 

Bilateral  Flap  Method  (Fig.  428,  c).— 
This  is  admirably  adapted  to  both  the  middle 
and  lower  thirds  of  the  thigh. 

The  outlines  of  the  flaps  are  integument- 
ary, and  are  dissected  up  from  the  muscles 
two  inches,  or  about  half  their  length.  The 
muscles  are  divided  by  a  circular  sweep  of  the 
knife,  and  the  bone  sawn  off  at  the  same  situ- 
ation. In  the  circular  division  of  the  mus- 
cles, accompanied  by  the  circular  or  equilat- 
eral flaps,  it  is  advisable  that  the  first  sweep  of  the  knife  should  divide 
only  the  superficial  layer,  which  will  then  retract  or  can  be  drawn  up- 
ward and  the  second  layer  be  severed  at  a 
higher  point,  causing  the  open  stump  to  pre- 
sent a  conical  cavity,  the  sawn  bone  corre- 
sponding to  its  apex  (Fig.  440).  The  end 
of  the  bone  is  then  seized  by  strong  forceps, 
the  soft  parts  on  its  posterior  surface  and 
sides  pushed  up,  and  with  a  small,  sharp- 
pointed  knife  an  oval  or  rectangular-shaped 
flap  of  periosteum  is  marked  out  and  pushed 
upward  from  the  anterior  surface  of  the  bone, 
together  with  the  soft  parts  resting  upon  it 
(Fig.  439,  a).  The  base  of  the  periosteal  flap 
must  correspond  to  the  point  of  secondary 
division  of  the  bone,  which  will  be  about  two 
inches  above  the  primary  section.  The  bone 
is  sawn  again  and  removed.  The  portion  of  the  flap  having  the  peri- 
osteum is  allowed  to  fall  into  its  proper  position  across  the  end  of 
the  divided  femur  ;  the  edges  are  united,  and  stump  dressed  as  desired. 


Fig.  439. — Periosteal  flap. 


Fig.  440. — Conical  cavity. 


AMPUTATIONS   OF   THE   LOWER   EXTREMITY. 


285 


Vermale  recommended  that  these  flaps  be  musculo-integumentary. 
Although  these  are  favorable  for  drainage,  their  weight  is  liable  to  lead 
to  exposure  of  the  bone  at  the  upper  angle  of  the  wound. 

Antero  -  posterior  Musculo-  integumentary 
Flops. — These  flaps  include  all  of  the  tissues 
down  to  the  bone,  and  are  made  by  transfixion 
usually,  although  the  anterior  one  may  be  made 
by  cutting  from  without  and  the  posterior  by 
transfixion  at  the  upper  limit  of  the  former. 
The  length  of  each  flap  should  be  about  one 
fourth  the  circumference  of  the  limb.  When 
both  flaps  are  to  be  made  by  transfixion,  the  tis- 
sues should  be  raised  somewhat  by  the  left  hand 
of  the  operator,  who  then  enters  the  point  of 
the  knife  at  the  side  nearest  himself,  pushes  it 
through  in  close  contact  with  the  anterior  sur- 
face of  the  bone,  and  raises  the  handle  a  little 
as  it  passes  to  cause  the  pomt  to  emerge  at  the 
opposite  side  of  the  limb,  exactly  opposite  the 
entrance.  This  flap  is  then  formed  by  cutting 
oblicpiely  upward  with  a  sawing  motion,  and 
when  completed  is  pulled  backward  by  an  as- 
sistant assigned  for  that  purpose.  The  kniTe  is 
reinserted  at  the  original  point  of  entrance,  car- 
ried behind  the  bone,  point  elevated  so  as  to 
emerge  at  the  same  situation  as  before,  and  the 
posterior  flap  is  made  by  cutting  obliquely 
downward.  The  remaining  muscular  fibers  around  the  bone  are  cut  by 
a  circular  sweep  of  the  knife,  retractors  applied  and  the  bone  divided. 
In  flaps  of  this  structure  the  skin  retracts  more  than  the  muscles, 
causing  the  lower  ends  of  the  latter  to  be  exposed.  To  avoid  this, 
Agnew  recommends  that  the  flaps  be  formed  first  from  the  integu- 
ment, reflected  up  an  inch  and  a  half,  and  the  muscles  be  divided 
by  transfixion  ;  the  point  of  the  knife  being  pushed  through  at  the 
junction  of  the  reflected  integumentary  flaps. 

Hie -Circular  Integumentary  Flap  method  can  be  employed  upon 
the  thigh,  and  with  admirable  results.  The  principles  governing  its 
construction  are  similar  to  those  applicable  to  this  method  in  other 
situations.  The  division  of  the  muscles  should  be  at  a  point  not  less 
than  two  inches  below  the  reflected  flap,  and  their  respective  layers 
should  be  divided  independently,  as  seen  in  Figs.  440  and  441. 

The  Singh  circular  Incision  Method  (Celsus). — Control  the  cir- 
culation, and  with  a  long  knife  divide  all  the  soft  parts  by  a  circular 
BWeep  down  to  the  hone  (Pig.  44:i),  which  18  then  sawn  off. 

The  end  of  the  divided  hone  is  now  seized  by  strong  forceps,  the 


Fig.  441. — Amputated 
portion. 


286 


OPERATIVE  SURGERY. 


surrounding  soft  parts  drawn  upward,  the  bone  exposed,  when,  if  de- 
sirable, an  oval  periosteal  flap  can  be  made,  its  base  corresponding  to 

the  site  of  secondary- 
section  of  the  bone 
(Fig.  439).  Saw  the 
bone  a  second  time 
close  to  the  periosteal 
flap,  and  allow  the 
parts  to  fall  into  po- 
sition. They  can  be 
united  transversely 
(Fig.  443)  or  the  re- 
verse ;  the  former  holds 
the  periosteal  flap  in 
position  the  better. 

Long  Anterior  Flap 
Method  (Sedillot).— 
This  can  be  employed 
in  any  portion  of  the 
thigh.  Mark  out  on 
the  anterior  surface  of 
the  limb  a  flap,  the 
length  of  which  is  equal 
to  one  third,  and  its 
base  to  two  thirds  of 
the  circumference.  Di- 
vide the  tissues,  ob- 
liquely, upward  and  backward,  not  making  the  flap  too  thick.  The 
tissues  on  the  posterior  por- 
tion of  the  limb  are  divided 
transversely  down  to  the 
bone,  which  is  then  exposed 
about  two  inches  higher  and 
sawn  off. 

Results. — The  rate  of  mor- 
tality, in  amputations  of  the 
lower  third  of  the  thigh  for 
gun-shot  injuries,  is  fifty- 
five  per  cent ;  at  the  middle 
third,  sixty-five  percent ;  and 
at  the  upper  third,  seventy- 
eight  per  cent.  About  thir- 
teen per  cent  more  recover 
with  expectant  treatment,  in 
gun-shot  injuries,  than  after  EiG.  443.— Appearance  of  stump. 


Fig.  442. — Celsus'  single  circular  incision. 


AMPUTATION'S   OF   THE   LOWER   EXTREMITY. 


28T 


amputation.  The  rate  of  mortality  after  primary  amputations  is 
twenty-one  per  cent  greater  than  after  secondary.  The  results  are 
considerably  more  favorable  when  done  in  private  practice,  or  with  an- 
tiseptic precautions,  irrespective  of  the  cause. 

Amputations  at  the  Hip. — The  causes  of  death  from  this  amputa- 
tion are,  loss  of  blood,  shock, 
and  septicaemia.  Various  plans 
to  limit  the  loss  of  blood  have 
been  suggested  —  compression 
of  the  abdominal  aorta  by  the 
fingers  of  a  hand  introduced 
into  the  rectum  by  an  assist- 
ant ;  combined  with  digital 
pressure  upon  the  femoral  as  it 
crosses  the  pubis.  In  all  in- 
stances, when  abdominal  pres- 
sure is  to  be  applied,  the  intes- 
tines should  be  evacuated.  Va- 
rious forms  of  tourniquets  have 
been  designed  for  the  purpose, 
as  Pancoast's  (Fig.  444),  Es- 
march's  (Fig.  445),  and  Lister's 
(Fig.  447).  Fig.  446  shows  Es- 
march's  elastic  tourniquet  in 
position. 

If  a  tourniquet  be  not  at  hand,  a  pad  may  be  substituted,  made  by 
winding  a  linen  bandage  about  three  inches  wide  and  twenty-five  feet 

in  length  around 
a  stout  rod  or 
stick,  one  inch  or 
so  in  diameter, 
and  twelve  inches 
long.  This  is 
placed  immediate- 
ly below  the  um- 
bilicus and  held 
in  position  by  an 
assistant. 

It  can  be  con- 
fined in  position, 
or  the  pressure  still  further  increased  by  several   turns  of  a  rubber 
bandage  carried  over  it  and  around  the  body  (Fig.  448). 

If  the  elastic  traction  around  the  body  be  objectionable,  a  longer 
-tick  can  be  substituted,  and  the  compress  secured  in  position  by  rubber 
bands  carried  over  the  ends  of  the  stick  and  under  the  table  (Fig.  449). 


Fig.  444. — Pancoast's  tourniquet. 


Fig.  445. — Esmarch's  tourniquet. 


288 


OPERATIVE   SURGERY. 


Davy's  lever  (Fig.  43)  is  a  useful  agent  to  control  bleeding  in  this 
situation. 

It  is  open  to  the  objection  of  being  easily  disturbed  by  the  struggles 
of  the  patient,  as  well  as  the  danger  of  injuring  the  intestines,  espe- 
cially when  carried  to  the  right  side  of  the  body. 

Trendelenburg' 's  Rod  (Fig.  44),  which  has  also  been  previously  men- 
tioned, is  of  unquestionable  utility.  It  is  a  steel  rod,  fifteen  or  six- 
teen inches  long,  about  one  fourth  of  an   inch  broad,  biconvex  on 


Fig.  446. — Esmarch's  tourniquet  applied. 


Fig.  44V. — Lister's  tourniquet. 


transverse  section,  and  a  twelfth  of  an  inch  thick  at  the  center,  with 
blunt  edges  ;  but  provided  with  a  movable  lance-shaped  point  two 


Fig.  448. — Compression  pad  and  elastic  band. 

inches  in  length.  The  rod  is  passed  through  the  soft  parts  in  front 
of  the  joint ;  entering  an  inch  and  a  half  below  the  anterior  superior 
spinous  process  of  the  ilium,  passing  across  the  femur  behind  the 


AMPUTATIONS   OF   THE    LOWER   EXTREMITY. 


289 


femoral  artery,  emerging  at  the  posterior  scroto-femoral  junction. 
The  point  is  removed  and  a  strong  elastic  tube  or  band  is  wound  firm- 
ly, like  the  figure  8,  around  its  ends,  passing  in  front  of  the  thigh. 


Fig.  449. — Drandis'  method. 


A  long  knife  is  then  inserted  in  the  course  of  the  rod  about  half  an 
inch  below  it,  and  the  anterior  flap  made  in  the  usual  manner,  and 
the  vessels  ligated.  The  rod  is  then  withdrawn,  the  hip-joint  dis- 
articulated, and  the  posterior  flap  made  in  a  similar  manner.  Dr. 
Varick,  of  Jersey  City,  N.  J.,  who  first  employed  the  rod  in  this 
country,  did  not  disarticulate  until  he  had  transfixed  a  second  time 
behind  the  neck  of  the  femur,  including  as  much  of  the  soft  parts  on 
the  posterior  surface  as  possible  ;  compression  was  then  applied  as  be- 
fore, and  the  tissues  were  divided  by  a  posterior  semicircular  incision 
down  to  the  bone.  The  amount  of  blood  lost  was  trifling,  and  the 
patient  made  a  speedy  recovery.  The  rod  can  be  employed  in  the 
various  forms  of  flaps,  and  therefore  has  an  element  of  universality. 
It  has  not  as  yet  been  enough  used  to  be  esteemed  more  than  a  rational 
expedient. 

A  seemingly  admirable  method  of  controlling  hemorrhage  in  am- 
putation at  the  hip-joint  has  recently  been  described  (Lloyd)  : 

"A  strip  of  black  india-rubber  bandage,  two  yards  long,  is  to  be 
doubled  and  passed  between  the  thighs,  its  center  lying  between  the 
tnber  ischii  of  the  side  to  be  operated  on  and  the  anus.  A  common 
calico  thigh  roller  must  next  be  laid  lengthwise  over  the  external 
iliac  artery.  The  ends  of  the  rubber  are  now  to  be  firmly  and  steadily 
drawn  in  a  direction  upward  and  outward,  one  in  front  and  one  be- 
hind, to  a  point  above  tlie  center  of  the  iliac  crest  of  the  same  side. 
They  nui-t  be  pulled  tight  enough  to  check  pulsation  in  the  femoral 
artery.     The  front  part  of  the  band,  passing  across  the  compress,  oo- 


290 


OPERATIVE   SURGERY. 


eludes  the  external  iliac  artery,  and  runs  parallel  to  and  above  Pou- 
part's  ligament.  The  back  half  of  the  band  runs  across  the  great 
sacro-sciatic  notch,  and,  by  compressing  the  vessels  passing  through 
it,  prevents  bleeding  from  the  internal  iliac  artery.  The  ends  of  the 
elastic  band  can  be  held  by  the  hands  of  an  assistant,  or  bandages  may 
be  tied  to  its  extremities,  and  passed  across  the  opposite  shoulder  and 
tied  ;  care  should  be  taken  to  prevent  the  compression  rollers  from 
slipping.  This  device  has  been  employed  on  several  occasions  with 
entire  satisfaction." 

Amputation  at  the  hip-joint  may  be  done  by  the  single-flap  method, 
anterior  or  internal ;  the  double  flap,  either  lateral  or  anteroposte- 
rior ;  the  oval  and  the  circular  forms. 

These  general  methods  have  been  modified  almost  indescribably, 
and  certainly,  in  many  instances,  impracticably. 

Amputation  by  a  Long  Anterior  and  Short  Posterior  Flap  (Manec). 
— Place  the  patient  on  a  table  so  that  half  the  pelvis,  on  the  side  to 
be  operated  upon,  projects  beyond  the  edge  ;  draw  the  scrotum  to  the 
opposite  side  by  a  towel  (Pig.  450).    Exsanguinate  the  limb  by  the  elas- 


■„.:■■■,      ■      ■'■■    .-,    ■  ■        ■ 


Fig.  450. — Manec's  method. 

tic  bandage  ;  after  which  control  the  hemorrhage  from  above  by  the 
form  of  arterial  compression  selected.  Then  remove  the  elastic  band- 
age ;  the  limb  to  be  amputated  is  held  by  one  assistant,  and  another  is 
instructed  to  control  the  circulation  in  the  femoral  artery  as  it  crosses 


AMPUTATIONS   OF   THE   LOWER  EXTREMITY. 


291 


the  pubes,  and  to  catch  the  anterior  flap  and  compress  it  before  it 
shall  have  been  severed  from  below. 

The  operator  then  introduces  the  point  of  a  long  knife,  midway 
between  the  anterior  superior 
spinous  process  of  the  ilium 
and  the  trochanter  major, 
pushing  it  down  to  the  bone 
parallel  with  Poupart's  liga- 
ment ;  draws  H  back  and  low- 
ers the  handle  ;  at  the  same 
time  the  assistant  holding  the 
leg  flexes  the  thigh  slightly, 
and  the  point  is  passed  through 
the  anterior  surface  of  the 
capsular  ligament ;  the  point 
is  then  turned  downward  and 
made  to  pass  out  at  the  inner 
side  of  the  thigh,  an  inch  or 
so  from  the  perineum,  and  as 
far  posteriorly  as  it  can  be  car- 
ried easily  (Fig.  451).  It  is 
then  carried  downward,  in  con- 


FiG.  452. — Making  posterior  flap. 


292 


OPERATIVE   SURGERY. 


tact  with  the  bone,  with  long,  sawing  strokes,  forming  an  anterior  flap 
six  to  eight  inches  in  length.  This  is  caught  by  an  assistant,  who  at  the 
same  time  compresses  the  main  vessel  within  it,  and  raises  it  upward. 
The  knife  is  then  brought  under  the  thigh  to  the  opposite  side  (Fig. 
452),  connecting  the  sides  of  the  base  of  the  anterior  flap  by  a  posterior 


Flaps  united. 


incision  extending  a  little  below  the  gluteal  fold,  and  carried  down  to 
the  bone  ;  after  which  the  bone  is  disarticulated,  by  dividing  the  cap- 
sular ligament  and  the  muscular  attachments  to  the  greater  and  lesser 
trochanters. 

Bring  the  flaps  into  position,  unite  with  sutures,  and  insert  a  long, 
large  drainage-tube  into  the  acetabulum,  allowing  it  to  protrude  at  the 
center  of  the  flaps  (Fig.  453). 

Circular  Method  (Dieff  en  bach's). — Control  the  hemorrhage  as  be- 


ature. 


fore,  or  by  means  of  the  elastic  ligature  (Fig.  454),  and  with  a  long 
knife  make  a  circular  incision  down  to  the  bone,  which  is  then  sawn 
through.     Tie  all  vessels,  veins  included.     If  it  be  impossible  to  em- 


AMPUTATIONS   OF   THE   LOWER   EXTREMITY. 


293 


ploy  the  bloodless  method,  the  femoral  vessels  should  be  secured  by- 
forceps,  or  ligatures  at  the  base  of  Scarpa's  triangle,  in  two  situations, 
and  the  vessels  be  divided  between  them,  the  proximal  end  allowed  to 
remain  until  the  operation  is  completed  (Fig.  455).  Eemove  the  elastic 
ligature,  secure  all  bleeding  points,  and  insert  a  knife  two  inches  above 
the  great  trochanter,  at  its  outer  side  ;  carry  it  down  to  the  bone,  over 
the  middle  of  the  trochanter,  along  the  outer  surface  of  the  femur  to 
the  circular  in- 
cision. Then 
seize  the  bone 
with  a  strong 
pair  of  forceps, 
separate  the 
edges  of  the  ver-  - 
tical  incision, 
and  remove  the 
periosteum  with  w, 
a  suitable  in- 
strument down 
to  the  points 
of  muscular  in- 
sertion. These 
must  be  sepa- 
rated by  a  knife 
with  the  edge 
directed  toward 
the  bone.  Ee- 
move the  peri- 
osteum   in   this 

manner  up  to  the  capsule  (lig.  456),  which  is  opened  and  the  head 
dislocated.  The  last  step  of  the  operation  is  attended  with  but  slight 
loss  of  blood.  Fig.  457  shows  the  appearance  of  the  parts  after  their 
coaptation.  An  additional  drainage-tube  is  inserted  at  the  lower  ex- 
tremity of  the  wound.  If  the  muscles  are  large,  the  flaps  can  be  va- 
riously modified  by  employing  either  the  ordinary  circular  or  the  long 
anterior  flap,  with  a  posterior  circular  incision  below  the  gluteal  fold. 

If  there  be  a  deficiency  of  tissue  on  the  anterior  surface  of  the 
thigh,  the  long  posterior  flap  can  be  supplemented  by  a  transverse  in- 
cision below  Poupart's  ligament,  remembering  to  pass  a  large  drainage- 
tube  in  the  course  of  the  retreating  extremities  of  the  divided  psoas 
and  iliacus  tendon-. 

Single-Flap  Method  (Malgaigne). — This  admits  of  rapid  execution, 
and,  wore  it  not  for  the  available  anaesthetic,  would  be  the  proper 
operation  to  select,  in  view  of  the  additional  shock  caused  by  the 
more  methodical  procedures  advocated  elsewhere. 


Fig.  455. — Dieffenbach1.1!  circular  method. 


294 


OPERATIVE   SURGERY. 


Having  controlled  the  circulation,  place  the  patient  on  the  table, 
with  the  hip  overhanging  the  edge.    The  surgeon,  standing  at  the  outer 


Fig.  456. — Removing  the  bone. 


side  of  the  limb,  which  is  slightly  flexed  and  separated  from  its  fellow, 
introduces  the  point  of  a  long  knife  midway  between  the  anterior  su- 
perior spinous  process 
of  the  ilium  and  the  top 
of  the   trochanter  ma- 
jor, directing  it  in  the 
course  of  Poupart's  liga- 
ment down  to  the  bone, 
from  which  it  is  care- 
fully  withdrawn,    and 
the    handle    depressed 
sufficiently    to    permit 
the  easy  passage  of  the 
point  of  the  knife  across 
the  neck  of  the  femur, 
and  through  the  anteri- 
or portion  of  the  capsule. 
If  the  handle  be  depressed  before  the  point  is  raised,  the  point 
may  be  broken.     The  handle  is  then  raised  and  pushed  onward  until 
the  point  emerges  an  inch  below  and  in  front  of  the  tuberosity  of  the 
ischium  (Fig.  458). 


Fig.  45*7. — Wound  closed. 


AMPUTATIONS   OF   THE   LOWER   EXTREMITY. 


295 


The  flap  is  then  made  by  carrying  the  blade  downward  six  or  eight 
inches  along  the  anterior  surface  of  the  bone,  parallel  with  its  line 
of  entrance,  when  it  is  brought  directly 
to  the  surface  (Fig.  430).  Before  the 
vessels  are  divided  an  assistant  seizes  the 
flap,  by  inserting  the  hands  into  the  in- 
cision, above  the  knife,  compresses  the 
vessels,  and,  when  severed,  carries  it  up- 
ward on  the  abdomen  (Fig.  459)  at  the 
same  time  the  surgeon  divides  the  re- 
maining anterior  portion  of  the  capsule 
with  the  point  of  the  knife  ;  another 
assistant  rotates  the  thigh  inward,  that 
he  may  sever  the  attachments  to  the 
great  trochanter,  then  quickly  rotates  it 
outward  and  abducts  it,  causing  the 
head  of  the  bone  to  escape  sufficiently 
to  expose  the  ligamentum  teres,  which 
the  surgeon  divides  with  the  point  of 
the  knife,  and  as  the  head  slips  from  its 
cavity  he  passes  the  blade  behind  it  (Fig.  459,  460),  seizes  the  head 


Fig. 
A 


458.  —  Malgaigne's    method. 

Point  of  entrance  of  knife. 
B.  Point  of  exit  of  knife.  C. 
Poupart's  ligament.  D.  Knife 
passing  through  capsule.  E.  Tro- 
chanter major. 


IV;.  159. — Compressing  femoral  vessels. 


of  the  bone  with   the  left  hand,  and  quickly  severs  the  posterior  tis- 
sues bv  an  incision  directed  downward  and  a  little  forward. 


296 


OPERATIVE   SURGERY. 


Fig.  460. — Passing  blade  behind  head  of  bone. 


The  lateral-flap  method  offers  no  advantages  over  the  anteropos- 
terior, excepting,  perhaps,  easier  drainage.  This  point,  however  im- 
portant it  may  have 
been  before,  like  the 
drainage  -  tube  of  the 
present  time,  can  not 
now  be  said  to  be  of 
such  marked  signifi- 
cance. 

Anterior  Oval  Meth- 
od (Verneuil). — Apply 
the  elastic  bandage  as 
far  up  as  consistent  with 
the  proposed  incision. 
Control  the  aorta  and 
make  an  incision  through 
the  integument  and  fas- 
cia, commencing  an  inch 
below  Poupart's  liga- 
ment, in  the  course  of 
the  femoral  vessels,  two 
inches  in  length  ;  con- 
tinue it  outward,  transversely  across  the  base  of  the  great  trochanter, 
to  the  gluteal  fold,  and  along  this  to  the  inner  side  of  the  thigh ; 
then  obliquely  upward  two  inches  below  the  genito-crural  fold,  to  the 
lower  end  of  the  vertical  incision.  Isolate  the  femoral  artery  and 
ligate  it  above  and  below  the  bifurcation  of  the  profunda,  and  likewise 
ligate  the  latter  a  little  distance  from  its  origin.  If  no  intervening 
branches  exist,  divide  the  femoral  between  the  ligatures,  isolate  the 
femoral  vein,  ligature  it  and  divide  in  the  same  manner.  Carry  the 
incision  through  the  muscles,  from  whichever  aspect  of  the  limb  is 
most  convenient,  seeking  for  and  ligating  all  bleeding  points  as  soon  as 
apparent.  Open  the  capsule  in  front,  divide  its  posterior  portion  as 
closely  as  possible  to  the  neck  of  the  femur,  together  with  the  remain- 
ing tendons  inserted  into  the  head  of  the  great  trochanter.  Depress 
the  thigh,  causing  the  wound  to  gape  widely,  and  divide  the  muscles 
on  its  inner  and  posterior  surface,  in  the  same  manner  as  those  preced- 
ing. Finally,  draw  down  the  sciatic  nerve,  and  cut  it  short  enough 
to  be  above  the  border  of  the  flap. 

The  tissues  left  are  not  sufficient  to  close  the  wound,  which  is 
dressed  with  a  thin  layer  of  tarletan  in  contact  with  the  cut  surface, 
upon  which  charpie  saturated  with  some  antiseptic  solution  is  placed, 
and  the  whole  covered  with  cotton  batting  surrounded  by  oiled  silk, 
which  is  held  in  position  by  a  simple  bandage.  The  wound  is  kept 
moist  with  the  antiseptic  solution. 


DEFORMITIES. 


297 


Results. — The  rate  of  mortality  is  governed  by  the  cause  calling 
for  the  operation. 

In  immediate  amputation  in  military  practice,  ninety-three  per 
cent  die. 

In  civil  practice,  the  mortality  after  the  primary  amputations 
reaches  eighty  per  cent.  Secondary  amputations  offer  better  results  ; 
sixty  per  cent  recover  in  the  civil  and  military  combined. 

The  results  are  more  favorable  in  non-traumatic  cases,  being  less 
than  forty-one  per  cent.  Taken  together,  the  rate  is  a  little  over 
sixty-four  per  cent,  being  a  trifle  more  than  for  amputation  in  the 
continuity  of  the  thigh,  which  is  about  sixty-three  and  a  half  per 
cent. 


CHAPTER  XL 

DEFORMI1IES. 


Deformities  may  be  either  congenital  or  acquired,  and  in  either 
case  they  can  be  referred  to  the  soft  or  hard  parts,  either  individually 
or  conjointly. 

The  acquired  deformities  calling  for  operation  in  a  special  sense 
depend  on  anchylosis  of  joints,  distorted  shafts  and  extremities  of 
bones,  irregular  or  unequal  muscular  contraction,  and  the  congenital 
fusion  of  parts.  To  overcome  the  deformities  dependent  upon  anchy- 
losis, we  resort  to  forcible  movement,  if  it  be  fibrous  ;  and  the  division 
of  the  bone,  or  joint  structure,  if  it  be  bony. 

The  forcible  breaking  of  an  anchylosed  joint,  while  not  an  opera- 
tion in  the  accepted  sense  of  the  term,  is  nevertheless  often  associated 
with  consequent  complications,  which  entitle  it  to  a  greater  degree  of 
prominence  than  many  accepted  operative  procedures. 

Brisement  Force,  as  it  is  sometimes  called,  should  be  preceded  by 
subcutaneous  section  of  all  the  tendons,  muscles,  and  fascia  upon 
which  "point  pressure"  causes  reflex  action. 

The  incisions  having  united,  place  the  patient  upon  a  hard  table, 
administer  an  anaesthetic,  and  while  the  portion  of  the  limb  between 
the  joint  and  the  body  of  the  patient  is  held  firmly  by  assistants,  the 
Burgeon  seizes  the  distal  portion  and  forcibly  flexes  it,  employing  steady 
and  persistent  force.  As  soon  as  moderate  movement  follows  flexion, 
it  is  then  forcibly  extended,  and  by  repeated  flexion  and  extension  the 
ran;"-  of  motion  of  the  joint  ig  re-established. 

If  the  knee  bo  the  one  in  question,  the  patella  must  be  loosened 
before  it  i.s  attempted.     After  the  operation  strap  the  toes  and  hand- 


298 


OPERATIVE   SURGERY. 


age  the  limb  from  the  toes  to  the  knee  firmly,  having  first  applied  ad- 
hesive plaster  for  the  purpose  of  extension.  Pad  the  popliteal  space 
with  cotton,  and  compress  the  knee-joint  with  strips  of  adhesive  plas- 
ter. Continue  the  roller  over  the  knee  and  up  the  thigh,  applying 
pressure  to  the  femoral  artery  by  means  of  a  small  piece  of  wet  sponge, 
applied  over  its  course  and  held  in  position  by  the  ascending  bandage. 
Place  the  patient  in  bed,  apply  extension,  with  the  foot  of  the  bed 
elevated,  also  ice-bags  to  the  knee,  the  limb  being  immovably  con- 
fined.    At  the  end  of  five  or  six  days  the  dressings  are  opened  and 

again  replaced,  after  slight  motion  is  made. 
The  sponge  over  the  femoral  artery  is 
omitted. 

If  the  anchylosis  be  tony,  the  deformity 
can  be  relieved  by  osteotomy  above  the 
condyles,  and,  if  necessary,  below  the  head 
of  the  tibia  at  the  same  time,  or  by  excision 
of  the  joint,  or  by  the  removal  of  a  trian- 
gular piece  above  the  joint,  having  the 
same  angle  as  that  formed  by  the  junction  of 
the  tibia  and  femur  in  the  popliteal  space. 
The  same  principle  can  be  applied  above 
the  knee  as  practiced  by  Barton  (Fig.  461). 
Boring  the  joint  and  other  expedients 
The  most 


Fig.  461. — Barton's  operation. 


have  been  resorted  to. 
satisfactory  of  all,  however,  is  os- 
teotomy above  the  condyles,  which 
is  described  under  that  heading. 

In  all  joints,  anchylosis  is 
amenable  to  the  same  procedures 
as  previously  stated. 

Deformities  caused  by  distor- 
tion of  the  long  bones  can  be  best 
corrected  by  osteotomy,  associated 
with  the  antiseptic  dressing. 

Curvature  of  the  Spine. —  A 
popular  method  of  treatment  at 
the  present  time  is  the  application 
of  the  plaster  -  of  -  Paris  dressing. 
The  body  of  the  patient  is  first 
surrounded  by  a  closely-fitting 
knit  jacket,  between  which  and 
the  region  of  the  stomach  is  in- 
troduced a  wedge-shaped  "din- 
ner-pad," with  the  point  down- 
ward ;  composed  of  several  thick- 


Fig.  462. — Apparatus  applied. 


DEFORMITIES. 


299 


nesses  of  cloth,  or  cotton  wadding  surrounded  by  it.     All  sensitive 
parts  and  projecting  points  should  be  relieved  from  direct  pressure  by 
spongio-piline,  cotton,  or  other  similar  ma- 
terial.    The  same  can  be  placed  over  the 
iliac  spines  and  the  adjoining  portions  of 
the  crest. 

"  The  mammary  glands  in  the  female 
should  be  protected,  and  suitable  space  be 
provided  by  the  introduction  of  properly 
shaped  pads. 

'•Tie  the  shirt  over  the  shoulders  and 
fasten  it  between  the  legs.  Then  the  pa- 
tient is  drawn  up  by  the  extending  appara- 
tus (Figs.  4G2,  4G3*,  and  464)  gently  and 
slowly  until  he  feels  perfectly  comfortable, 
and  never  beyond  that  point.  A  prepared,  FiG.  463. — Extension  apparatus, 
saturated  plaster-of-Paris  roller  having  been 

gently  scmeezed,  so  that  all  sur- 
plus water  is  removed,  is  now 
applied  around  the  smallest  part 
of  the  body,  and  is  carried  round 
and  round  the  trunk  downward 
to  the  crest  of  the  ilium  and  a 
little  beyond  it ;  afterward  in  a 
spiral  direction  from  below  up- 
ward, until  the  entire  trunk 
from  the  pelvis  to  the  axilloe  has 
been  incased. 

"The  bandage  should  be 
placed  smoothly  round  the  body, 
and  must  not  be  drawn  tight ;  it 
should  be  simply  unrolled  with 
one  hand  while  the  other  follows 
and  brings  it  into  smooth  close 
contact  with  all  irregularities  of 
the  trunk. 

"After  one  or  two  thick- 
nesses of  bandage  have  been 
placed  around  the  body  in  the 
manner  described,  narrow  strips 
of  roughened  tin  can  be  placed 
parallel  with  each  other  on  either 
side  of  the  spine,  if  the  case  re- 
quires it,  with  intervals  of  two 
Fta.  -164.— Body  extended.  or  three  inches,  and  in  number 


300 


OPERATIVE   SURGERY. 


sufficient  to  surround  the  body.  Over  these  another  plaster  bandage 
is  applied.  In  a  very  short  time  the  plaster  sets  with  sufficient  firm- 
ness, so  that  the  patient  can  be  removed  from  the  suspending  appa- 
ratus and  laid  upon  his  face  or  back  on  a  hair  mattress,  or,  what  is 
preferable,  especially  when  there  is  much  projection  of  the  spinous 
processes  or  sternum,  an  air-bed.  Before  the  plaster  has  completely 
set,  the  "dinner-pad"  is  removed,  and  the  plaster  gently  pressed  in 
with  the  hand,  in  front  of  each  anterior  iliac  spinous  process,  for  the 
purpose  of  molding  the  case  over  the  bony  projections. 

"  While  the  jacket  is  drying  it  is  necessary,  sometimes,  to  wet  it 
with  a  little  water  and  dust  it  with  more  plaster.  The  surgeon  often 
leaves  some  weak  spots  that  need  strengthening  in  this  manner."  The 
preceding  is  a  description  as  recorded  by  Dr.  Sayre,  to  whom  the  pro- 
fession is  indebted  for  the  prominence  which  has  been  given  this 
method. 

The  Deformities  dependent  upon  Perverse  Muscular  Action  are,  in 
an  operative  sense,  relieved  by  subcutaneous  division,  called  myotomy 
and  tenotomy,  which  has  been  before  considered. 

Deformities  due  to  Fusion  of  the  parts  and  supernumerary  attach- 
ments, like  webbed  fingers  and  toes,  and  supernumerary  digits,  al- 
though not  common,  are,  nevertheless,  entitled  to  some  consideration. 
Webbed  Fingers. — The  operative  treatment  will  depend  very  much 
upon  the  extent  as  well  as  the  thickness  of  the  attachments  ;  whether 
the  connections  be  limited  to  the  soft  parts  alone,  or  the  bones  be 
fused.  Digits  that  are  united  by  their  extremities  only  can  easily  be 
separated  by  the  division  of  the  tissues  which  connect  them.     If  they 

be  united  their  entire  length,  even  then 
an  incision  in  the  median  line  of  their 
attachments,  down  to  the  line  of  the 
normal  web,  may  be  sufficient  to  effect 
a  cure,  if  the  tissues  connecting  them 
be  not  too  thick  ;  if  such  be  the  case, 
great  difficulty  is  often  experienced  in 
healing  the  divided  surfaces,  owing  to 
the  tendency  to  reunion  at  their  point 
of  junction.  To  obviate  this,  various 
expedients  have  been  recommended, 
one  of  which  is  to  introduce  a  rubber 
seton  at  the  base  of  the  malformation, 
on  a  line  with  the  normal  web  of  the 
hand,  and  allow  it  to  remain  until  the 
opening  becomes  permanent  (Fig.  465), 
when  the  remaining  portion  is  divided 
and  the  borders  united  by  sutures.  Anotherplan  is  to  make  a  trian- 
gular flap  from  the  posterior  portion  of  the  web,  the  base  to  remain 


Fig.  465.— Webbed  finders. 


DEFORMITIES. 


301 


attached,  and  to  correspond  in  shape  and  size  to  the  space  between  the 
knuckles. 

Its  apex  is  of  course  directed  to  the  free  edge  of  the  abnormal  at- 
tachment. The  flap  having  been  raised,  the  remaining  portion  of  the 
attachment  between  the  fingers  is  divided,  and  the  triangular  flap 
adjusted  to  the  base  of  the  cleft,  and  kept  in  position  until  union 
takes  place.  The  remaining  borders  of  the  wound  are  united  by  su- 
tures the  same  as  before. 

It  has  been  suggested  to  make  two  such  flaps,  one  on  the  palmar 
and  one  on  the  dorsal  aspect,  in  the  same  situation  ;  to  cut  off  their  ex- 
tremities and  unite  them  at  the  cleft,  when  the 
remaining  portion  can  be  divided  longitudinally. 

Another,  a  very  effectual  and  ingenious 
method,  is  best  described  by  M.  Nelaton,  its  de- 
signer :  "A  longitudinal  incision  is  made  in  the 
center  of  the  phalanx  of  one  finger  on  the  dorsal 
aspect,  for  the  posterior  flap  ;  on  the  palmar  as- 
pect of  the  other  for  the  dorsal  flap,  the  length 
of  the  incision  will  correspond  with  the  depth 
of  the  web.  From  either  extremity  of  the  longi- 
tudinal incision,  a  small  transverse  one  is  to  be 
made  toward  the  phalanx  of  the  connected  finger 
(Fig.  466,  B).  The  lower  transverse  incision 
will  correspond  to  the  free  edges  of  the  web  ; 
the  upper  one  will  cross  the  cleft  between  the 
fingers.  Each  flap  is  now  to  be  dissected  back  toward  the  contiguous 
fingers.  In  doing  this  the  two  folds  of  the  web  will  be  separated  from 
each  other,  one  entering  into  the  formation  of  the  posterior  flap,  the 
other  into  the  formation  of  the  anterior.  Each  flap  will  now  be  found 
to  be  attached  by  one  edge  only,  and  is  to  be  wrapped  around  the  de- 
nuded surface  of  the  finger  to  which  it  is  attached.  The  flaps  are  to 
be  adjusted  by  strips  of  adhesive  plaster,  and  by  sutures." 

Annandale  says  :  "  The  principal  objection  to  this  ingenious  opera- 
tion appears  to  me  to  be  that  it  necessitates  cutting  into  the  palmar 
and  dorsal  aspects  of  the  fingers  in  order  to  get  a  flap  to  cover  their 
sides."  If  the  web  or  fold  of  the  skin  be  loose,  he  deems  it  pref- 
erable "  to  make  the  longitudinal  incision  along  the  sides  of  each 
finger  instead  of  along  the  center  of  the  dorsal  and  palmar  aspects." 
Triangular  flaps  may  be  made  at  the  base  of  the  web,  and  the  remain- 
der cut  directly  through  (Fig.  466,  A).  If  N61aton'e  operation  be 
performed,  care  must  be  taken  in  uniting  the  flap,  or  sloughing  will 
follow.  When  the  joints  of  the  digits  are  fused,  it.  is  not  wise,  as  a 
rule,  to  attempt,  their  separation,  since,  though  it.  be  accomplished, 
the  remaining  digit  may  have  its  function  greatly  impaired  ;  however, 
this  course  is  not  so  imperative  now,  since  the  advent,  of  antisepsis.    If 


Fig.  466. — Nekton's 
method. 


302 


OPERATIVE   SURGERY. 


a  supernumerary  digit  possess  an  independent  articulation,  it  can  be 
removed  without  any  great  danger  to  its  associate. 

Ingrowing  Toe-nail.— This  is  quite  a  common  affliction,  to  the 
relief  of  which  various  palliative  measures  have  been  directed.  As 
a  rule,  however,  they  have  been  found  inadequate  to  effect  a  cure. 
This  condition  is  largely  induced  by  improperly  fitting  boots  and 
shoes,  although  in  some  persons  there  exist  additional  predisposing 
causes.  Going  barefooted  would  in  a  ma- 
jority of  cases  bring  about  a  speedy  cure,  but, 
since  this  is  impracticable,  operative  measures 
are  often  necessary. 

Operation. — When  the  affection  is  fully 
established,  administer  an  anaesthetic,  and 
with  a  sharp-pointed  scalpel  divide  the  nail 
its  whole  length  on  a  line  with  its  ingrowing 
portion  (Fig.  467),  which  portion  can  then  be 
quickly  and  easily  removed  by  a  thin-bladed 
pair  of  forceps,  or  a  narrow  spatula  passed 
beneath  it.  If  the  other  side  be  affected,  it 
too  should  be  removed  in  the  same  manner. 
Cauterize  the  exposed  matrix  and  apply  a  hot 
anodyne  poultice  at  once.  The  patient  must 
keep  quiet  until  the  tenderness  has  in  a  meas- 
ure subsided.  In  no  instance  ought  the  entire 
nail  to  be  removed,  unless  it  be  diseased. 

Bunion. — This  affliction  is  accompanied  in 
a  large  proportion  of  cases  by  malposition  of  the  great  toe  (Fig.  468), 
and  an  increase  in  the  normal  size  of  the  bursa,  or  the  development 
of  an  adventitious  one.  The  operative  means  for  relief  consist  either 
in  the  excision  of  the  bursa,  or  its  subcuta- 
neous division  into  numerous  fragments  by 
means  of  a  narrow  tenotome.  If  these  means 
fail,  a  sufficient  amount  of  the  metatarsal 
bone  should  be  excised  to  admit  of  the  toe 
being  returned  to  its  normal  position,  or  the 
operation  described  on  page  222  can  be  per- 
formed, after  which  the  toe  is  confined  in 
place  until  recovery  is  established. 

Flat  Foot—  Og  si  oris  Operation.—  With 
the  foot  lying  on  its  outer  side,  an  incision  an 
inch  and  a  quarter  in  length  is  made  paral- 
lel with  the  sole  down  to  and  at  the  inner 
side  of  the  bones  forming .  the  astragalo-scaphoid  articulation.  The 
ligamentous  structures  are  detached  from  the  bones  for  half  an  inch 
at  either  side  of  the  wound,  with  a  knife  and  periosteal  elevator.     As 


Fig.  467. — Ingrowing  nail. 


Fig.  468.- 


—Bunion  with   hal- 
lux valgus. 


DEFORMITIES.  303 

soon  as  the  contiguous  articular  surfaces  of  the  scaphoid  and  astragalus 
are  well  exposed,  they  are  denuded  of  their  cartilage  and  of  a  sufficient 
amount  of  bone  to  permit  the  correction  of  the  deformity  and  the  per- 
fect coaptation  of  the  cut  surfaces.  The  surfaces  are  then  fastened  to- 
gether by  ivory  pegs  or  by  wiring.  If  the  motion  between  the  internal 
cuneiform  and  scaphoid  bones  be  unusually  free,  their  contiguous 
surfaces  can  be  treated  in  a  similar  manner  instead. 

Results. — If  performed  with  strict  antisepsis,  the  danger  to  life  is 
slight.  The  anchylosed  arch  gives  the  patient  a  useful  foot.  Stokes' 
operation,  it  is  claimed,  corrects  the  deformity,  which  if  true  makes 
it  much  the  more  preferable  operation,  as  it  does  not  involve  the  joint. 

Astragaloid  Osteotomy  (Stokes). — This  operation  is  recommended 
to  relieve  the  deformity  of  flat  foot,  and  should  only  be  conducted 
under  strict  antiseptic  precautions. 

Operation. — Make  an  incision  an  inch  and  a  half  in  length  along 
the  inner  side  of  the  foot,  the  center  of  which  should  correspond  to 
the  prominence  caused  by  the  head  of  the  astragalus  ;  at  the  center  of 
this  another  is  made  about  three  fourths  of  an  inch  in  length  at  right 
angles  to  it,  and  situated  a  little  behind  the  medio-tarsal  joint. 
The  triangular  flaps  thus  formed  are  dissected  back  half  or  three 
fourths  of  an  inch.  A  wedge-shaped  piece  of  bone  is  then  removed 
from  the  head  and  neck  of  the  astragalus  with  an  osteotome  ;  the  foot 
adducted  and  supinated,  in  which  position  it  is  retained  until  recovery 
takes  place. 

Results  have  thus  far  been  satisfactory,  but  as  yet  there  are  not 
sufficient  data  itpon  which  to  estimate  a  mortality  record. 

Tarsectomy. — In  old  and  obstinate  cases  of  talipes  varus  and  equi- 
no-varus,  this  method  of  treatment  has  .been  performed  with  varying 
success  for  a  long  time. 

Operation. — Place  the  foot  on  its  inner  side  and  make  an  incision 
parallel  to  the  sole  down  upon  the  outer  border  of  the  cuboid  bone, 
its  entire  length,  and  expose  its  upper  and  lower  surfaces  by  means  of 
a  knife  and  periosteotome,  carefully  protecting  the  surrounding  soft 
parts  from  injury.  A  triangular  piece  of  bone,  with  the  base  outward, 
is  then  removed  from  the  cuboid  of  sufficient  dimensions  to  admit  of 
the  correction  of  the  deformity.  In  extreme  cases  the  entire  cuboid 
and  even  portions  of  the  contiguous  bones  may  be  included  in  the  base 
of  the  wedge.  As  soon  as  the  deformity  can  be  reduced,  the  bony 
surfaces  arc  wired  together,  the  limb  dressed  antiseptically,  and  the 
foot  confined  in  the  corrected  position  until  recovery  takes  place. 

/.'  ults. — When  cautiously  done,  the  dangers  to  life  do  not  con- 
tniindicate  the  measure,  and  the  usefulness  of  the  limb  is  very  much 
enhanced. 


304;  OPERATIVE   SURGERY. 

CHAPTEE  XII. 

FLASTIC  SURGERY, 

This  form  of  operative  surgery  relates  to  the  various  means 
adopted  to  overcome  or  alleviate  the  deformities  of  aspect  and  func- 
tion resulting  from  congenital  defects,  disease,  and  accidents. 

Inasmuch  as  the  successful  issue  of  these  operations  depends  far 
more  on  the  careful  attention  to  the  details  and  small  matters  con- 
nected with  them  than  anything  else,  it  is  well  for  the  operator  to 
understand  at  once  that  there  is  no  precaution  too  trifling  to  be 
treated  with  indifference. 

Preparation  of  the  Patient.— The  patient  ought  to  be  in  a  vigorous 
physical  condition,  his  appetite  and  functions  normal,  and  the  sur- 
roundings of  such  a  character  as  to  combine  quietude  of  mind  with 
close  and  gentle  attention.  No  association  can  be  allowed  with  putre- 
factive processes,  or  diseases  known  to  engender  changes  derogatory 
to  union  and  repair.  Prior  to  the  operation,  the  part  should  be  puri- 
fied by  a  solution  of  carbolic  acid  or  other  suitable  agent. 

Size  of  the  Flap. — The  shape  and  size  of  the  flap  must  be  ascer- 
tained by  careful  measurement.  A  pattern  of  the  deformity  to  be  re- 
paired is  to  be  carefully  cut  out  and  used  to  outline  the  tissues  to  be 
employed  in  filling  the  gap,  since  the  contractile  power  of  the  normal 
tissues,  when  loosened  from  their  underlying  attachments,  causes 
enough  shrinkage  to  require  undue  force  to  maintain  proper  coapta- 
tion of  the  borders.  The  reparative  flaps  must  always  be  made  large 
enough  to  admit  of  at  least  three  lines  of  shrinkage  to  each  inch  of 
their  surface. 

In  choosing  the  material  to  form  the  flap,  it  is  necessary  that  it 
consist  of  sound,  healthy  skin  ;  and  under  no  consideration  can  cica- 
tricial tissue  possessed  of  a  pale,  glossy  surface  be  employed  ;  for, 
when  its  subcutaneous  connections  are  severed,  it  is  almost  certain  to 
slough,  especially  when  the  result  of  a  burn.  The  thickness  of  the 
flap  should  be  sufficient  to  include  all  the  vessels  that  normally  afford 
it  nourishment.  The  relation  which  cicatricial  tissue  bears  to  a  flap  is 
all-important.  If  it  exists  at  its  base,  sloughing  is  quite  certain  to  occur. 
Cicatricial  tissue  at  the  border  of  a  flap  is  quite -certain  to  die,  and  its 
presence  must  not  be  estimated  in  computing  the  area  of  the  ne>»  i^ap. 
When  the  new  flap  is  to  be  surrounded  on  three  sides  by  cicatricial 
formations,  its  base  must  be  large,  vascular,  and  but  little  twisted,  as 
the  medium  of  supply  at  its  sides  will  be  very  much  lessened  by  its 
new  association.  The  long  axis  of  the  flap  should  correspond  to  the 
course  of  the  vessels  from  which  it  derives  its  nourishment,  and  its 
base  must  be  located  as  nearly  as  possible  to  the  nutrient  vessels. 
All  hemorrhage  must  be  checked  before  the  flaps  are  united,  since  it 


PLASTIC   SURGERY.  305 

not  infrequently  happens  that  a  thin  clot  of  blood  prevents  union. 
The  direction  of  the  flap  should  be  such  that  it  can  be  placed  with 
the  least  twisting  of  the  pedicle.  The  silver  wire  and  carbolized  silk, 
or  horse-hair,  make  efficient  sutures,  which  should  not  be  drawn 
tightly.  To  avoid  the  danger  of  ulceration  at  the  pressure  points, 
small  squares  of  carbolized,  bibulous,  or  unglazed  paper,  having  a 
diameter  of  half  an  inch  or  less  (Fig.  409),  with  small 
holes  through  the  center,  or  punctured  through  the  cen- 
ter by  the  pin  or  needle  carrier  at  the  time  of  carrying 
the  ligature,  can  be  used  to  tie  them  upon.  The  edges 
of  flaps  may  be  beveled  ;  this  increases  the  width  of  the 
opposed  surfaces,  and,  when  combined  with  undercutting  fig.  469._pa- 
of  the  other  borders,  increases  the  chances  of  union.  A  Pcr  protective, 
small  slip  of  the  aseptic  bibulous  paper  can  be  placed  be- 
tween the  sutures  and  the  edges  of  the  wound  at  the  point  of  crossing. 
The  use  of  carbolized  cotton  yarn,  which  is  to  be  frequently  changed, 
in  connection  with  the  plastic  pins,  offers  a  soft  and  otherwise  ad- 
mirable retaining  agent. 

If  small  pins  be  inserted  to  indicate  the  extent  of  flaps,  the  incis- 
ions will  be  made  more  accurately  than  if  they  be  formed  by  the  aid 
of  the  eye  alone. 

Methods  of  Transfer. — The  methods  of  transfer  may  be  classified 
into  six  general  forms,  with  their  subdivisions  :  1.  Sliding  in  a  direct 
line.  2.  Sliding  in  a  curved  line.  3.  Jumping.  4.  Inversion,  or 
e version.     5.  The  Taliacotian.     6.  Grafting. 

Sliding  in  a  Direct  Line. —  TJie  first  and  simplest  variety  of  this 
method  consists  in  uniting  the  lips  of  an  ordinary  incision,  and  is 
sometimes  called  "  simple  approximation  of  divided  surfaces." 

The  second  variety  is  called  "  undercutting,"  and  consists  in  cut- 
ting under  the  edges  of  the  incision  at  each  side,  and  drawing  them 
together. 

The  third  variety  consists  in  sliding  in  a  direct  line,  by  aid  of  par- 
allel incisions  on 
both  sides  of  the 
primary  one,  which 
is  closed.  The  out- 
side incisions  are  al- 


Fig.  470.-" Parallel  incisions.        Fig.  471.— Opening  closed.        lowed     to     heal     by 

gran  illation  ( Figs. 
470  and  471).  Undercutting  in  this  method  lessens  the  tendency  to 
reparation  of  the  parallel  lines. 

In  the  fourth  method  the  liberating  incisions  are  made  transversely, 
that  is,  at  ri^ht  angles  to  the  extremities  of  the  oval  opening,  and 
undercutting  is  employed  (Figs.  172  and  473)  to  enable  this  opening 
to  be  closed.     The  uppermost  curve  is  undercut,  and  the  lowermost  is 

20 


306 


OPERATIVE   SURGERY. 


Fia.  472. — Transverse 
incision. 


Fig.  473.—  Open- 
in  tr  closed. 


liberated  by  a  combination  of  undercutting  and  sliding  by  the  aid  of 
the  transverse  incisions.     If  this  method  be  applied  to  those  parts 

which  can  not  resist  the  traction  of 
the  displaced  tissue,  a  second  de- 
formity is  liable  to  follow. 

Sliding  in  a  Curved  Line. — This 
operation    can  be    done  with  flaps 
having  either  curved  or  angular  bor- 
ders.    In  the  former  instance,   the 
space  from  which  the  flap  is  taken  is 
filled   by   undercutting  its    borders 
and  drawing  them  together.     In  the 
latter,   the  space  is  usually  allowed 
to  granulate. 
Jumping. — Jumping,  as  the  name  implies,  consists  in  "jumping 
a  flap  connected  by  a  pedicle  over  intervening  undetached  tissues." 
It  can  be  done  with  or  without  the  pedicle  being  twisted. 

If  the  flap  be  not  moved  more  than  a  quarter  of  a  circle,  twisting 
of  the  pedicle  is  not  necessary.  Undercutting  is  employed  in  this 
operation  when  necessary  to  adjust  the  parts  properly. 

The  plan  of  operation  without  twisting  the  pedicle  is  shown  in 
Fig.  474.  When  the  flap  is  moved  more  than  a  quarter  of  a  circle, 
the  pedicle  will  be  twisted,  and  the  degree  of  twisting  will  depend  on 
the  distance  the  flap  is  moved. 

If  the  pedicle  be  too  much  twisted,  the  circulation  of  the  flap  will 
be  impeded,  and  sloughing  may  ensue. 


Fig.  474. — Jumping  method. 

Inversion  or  Eversion— -These  methods  relate  simply  to  the  em- 
ployment of  integument  in  the  repair  of  mucous  membrane,  or  vice 
versa.  Tubular  formations  may  be  constructed  by  either  of  these 
methods,  as  in  the  formation  of  new  canals,  like  the  urethra,  vagina, 
and  the  closure  of  an  extroverted  bladder. 

The  Taliacotian  Operation.— -This  operation  is  familiarly  known 
as  the  dissection  of  a  flap  from  another  and  distant  portion  of  the 


PLASTIC  SURGERY.  397 

body,  allowing  it  to  granulate,  and  applying  it  to  the  part  to  be  re- 
paired, as  is  done  in  the  ordinary  operation  for  the  construction  of  a 
new  nose. 

Grafting. — This  method  is  but  little  employed,  and  the  operation 
is  performed  by  entirely  removing  a  flap  from  one  place  to  the  local- 
ity to  be  repaired. 

Skin-grafting,  in  the  common  acceptation  of  the  term,  is  employed 
to  cause  the  healing  of  extensive  granulating  surfaces,  when  of  a 
healthy  character.  It  is  performed  by  first  making  small  punctures 
in  the  granulating  surface  with  the  sharp  end  of  the  common  pocket- 
probe,  half  an  inch  or  so  apart  ;  and,  second,  by  placing  over  the 
open  mouths  of  these  shallow  punctures  small  pieces  of  integument, 
a  line  or  two  square,  with  the  fresh  surface  downward.  They  are 
then  pushed  into  the  openings  of  the  punctures,  by  the  same  probe,  in 
such  a  manner  as  to  cause  a  close  contact  between  the  raw  surfaces  of 
the  small  "grafts"  and  those  of  the  punctures  in  the  granulating 
surface.  Small  pieces  of  lint  are  placed  over  each  "graft,"  and  the 
whole  is  confined  in  position  by  narrow  strips  of  adhesive  plaster.  The 
part  should  be  carefully  redressed  at  the  end  of  three  or  four  days. 

Rhinoplasty. — This  operation  consists  in  the  reproduction  of  a  part 
or  the  whole  of  the  nasal  organ.  The  present  ability  of  the  surgeon 
to  arrest  the  diseases  causing  deformities  of  the  nose  has  lessened  the 
frequency  of  this  operation.  Ingenious  contrivances  of  ivory,  rubber, 
etc.,  have  been  made  to  fit  the  nose,  and  to  thus  supply  a  substitute 
for  the  lost  parts.  These  contrivances,  when  tinted  to  conform  to  the 
complexion  of  the  wearer,  often  prove  quite  deceptive  to  the  observer  ; 
but,  being  unaffected  by  the  various  contingencies  of  the  weather  and 
the  emotions,  they  are  apt  at  times  to  cause  the  wearer  to  present  a 
ludicrous  appearance.  In  operating  on  the  nose,  save  all  that  is  possi- 
ble of  its  cartilaginous  and  bony  tissues,  for  they  will  each  afford  im- 
portant supports  for  the  new  structure.  The  cartilages  of  the  alae 
should,  when  possible,  constitute  the  free  border  of  the  new  structure. 
The  deformities  of  this  organ  may  be  due  :  1,  to  a  loss  of  the  su- 
perficial soft  parts,  which  may  vary  in  extent  and  degree  ;  2,  to  a  loss 
of  the  bony  or  cartilaginous  septum,  with  or  without  loss  of  the  nasal 
bones;  3,  to  a* loss  of  both  combined.  The  soft  parts  may  be  restored 
by  either  of  the  five  methods  before  named.  The  extent  of  the  deform- 
ity and  its  situation  will  determine  the  choice  of  a  method.  When  the 
lose  of  the  integument  is  small  and  does  not  involve  the  alae  and  the 
deeper  structures,  the  deformity  may  be  remedied  by  the  direct  ap- 
proximation of  its  borders,  aided,  of  course,  by  a  free  undercutting 
with  or  without  parallel  incisions.  The  French  method,  by  transverse 
incisions  combined  with  undercutting,  can  be  employed  (Fig.  475) 
when  the  former  is  deemed  inadequate.  If  the  extremity  of  the  nose 
or  the  aloe  be  involved,  the  second   method,  or  "sliding  in  a  curved 


308 


OPERATIVE  SURGERY. 


line,"  the  flap  having  either  curved  or  angular  borders,  is  recom- 
mended.   Fig.  476  represents  the  restoration  of  the  alse  by  a  flap  taken 


\3 


Fig.  4*75. — Closure  by  transverse  incisions. 


Fig.  476. — Repair  by  sliding 


from  the  cheek  (a).  It  must  be  of  sufficient  size  to  allow  at  least  one 
fourth  for  its  contraction,  otherwise,  when  united  in  position,  it  will 
displace  the  axis  of  the  nose,  thereby  substituting  one  deformity  for 

another.  Langen- 
beck  repaired  a 
similar  deformity 
by  taking  a  flap 
from  the  opposite 
side  of  the  nose  (b). 
As  in  the  preceding 
method,  the  dissec- 
tion must  be  care- 
fully made  down  to 
the  cartilaginous 
frame-work.  The 
border  of  the  new 
ala,  although  fresh- 
ly cut,  heals  in  a 
satisfactory  man- 
ner. Fig.  477  shows 
the  line  of  incision 
employed  to  repair 
the   deformity  with  a  flap  possessing  an  already  cicatrized  border. 


Fig.  47*7. — Repair  by  sliding. 


PLASTIC   SURGERY. 


309 


Fig.  478. — Repair  by  jumping. 


The  vascular  supply  of  this  flap  is  not  active,  arid  every  precaution 
should,  therefore,  be  taken  to  provide  against  the  danger  of  slough- 
ing. If  either  ala  be  absent, 
and  the  resulting  gap  be  a 
large  one,  the  material  for  its 
repair  can  be  taken  from  the 
forehead,  as  shown  in  Figs. 
478  and  479.  It  will  be  seen 
that  the  pedicles  are  admira- 
bly located  to  receive  ample 
nourishment.  The  loss  of  an 
ala  or  of  the  end  of  the  nose 
may  be  repaired  from  the  tis- 
sue of  the  upper  lip  (Fig.  480) 
or  the  cheek. 

If  the  columna  be  absent, 
it  may  be  replaced  by  struc- 
tures taken  from  the  upper 
lip.  In  this  operation  it  is 
better  to  include  the  whole 
thickness  of  the  lip,  tipping 
the  flap  directly  upward  into 
place,  than  to  make  an  integ- 
umentary flap,  the  adjustment  of  which  will  require  a  smart  twisting 
of  the  pedicle.     In  the  former  instance  the  cuticle  is  dissected   off 

and  the  raw  surface  carried 
directly  into  its  position.  The 
mucous  surface  of  the  flap 
soon  assumes  integumentary 
characteristics.  If  the  lip  be 
deficient  at  the  point  of  se- 
lection, a  flap  can  be  taken 
from  beneath  either  ala  and 
carried  into  place. 

Loss  of  the  Bony  or  Car- 
tilaginous Septum,  with  or 
without  Loss  of  the  Nasal 
Bones. — The  loss  of  the  carti- 
laginous portion  of  the  sep- 
tum, the  other  tissues  remain- 
ing intact,  causes  a  flattening 
of  the  end  of  the  nose,  or  a 
depression  at  the  lower  end  of 
the  nasal  bones.  The  opera- 
tion of  sliding  the  tisi  liefi  may 


Vic.  ■179. — Repair  by  jumping. 


310 


OPEKATIVE   SURGERY. 


Fig.    4S0.  —  Repair 
by  jumping. 


temporarily  relieve  the  deformity  ;  but  traction  of  the  flap  and  various 
interferences  from  without  soon  reproduce  it. 

Mechanical  ingenuity  bids  fair  to  afford  more 
relief  for  this  deformity  than  surgical,  especially  if 
the  defect  be  associated  with  an  opening  through 
the  hard  palate.  If  the  nasal  bones  be  intact,  the 
loss  of  the  bony  septum  is  not  manifested  by  any 
external  deviation  of  the  organ.  If  both  the  septum 
and  nasal  bones  be  gone,  it  then  becomes  necessary, 
in  order  to  relieve  the  deformity,  to  elevate  and 
maintain  in  position  the  tissues  composing  the  soft 
parts  of  the  nose.  To  accomplish  this  requires  an 
internal  support  of  some  sort,  although  much  may 
ba  gained  by  dissecting  up  the  soft  parts  on  each 
side  of  the  nose,  and  raising  them  in  the  line  of  the 
bridge  by  approximating  their  bases  in  position  by  means  of  pins 
passed  through  them,  and  confining  them  until  union  of  the  flaps 
takes  place.  In  1829  Dieffenbach  published  a  method  of  performing 
an  operation  by  which  he  overcame  the  deformity  resulting  from  the 
loss  of  the  nasal  bones  and  the  septum.  An  incision  was  made  with  a 
narrow-bladed  knife  along  the  outer  side  of  the  sunken  border  of  each 
nostril,  the  intervening  strip  being  three  times  broader  at  its  connec- 
tions with  the  upper  lip  than  above  where  it  joined  the  forehead.  At 
the  outer  side  of  each  of  these  incisions,  another  was  made  down  to  the 
bone,  which  began  a  few 
lines  below,  and  to  the  outer 
side  of  the  first,  and  was 
carried  obliquely  down- 
ward, parallel  with  the  pri- 
mary one,  and  external  to 
the  side  of  the  nose,  around 
into  the  nostril,  thereby 
separating  the  ala.  The 
columna  was  elongated  by 
short  parallel  incisions  in 
the  upper  lip,  and  the 
cheeks  were  dissected  up 
from  their  bony  attach- 
ments, through  the  lateral 
cuts,  sufficiently  to  render 
them  freely  movable.  The 
flaps  were  then  raised,  their 
borders  were  pared  oblique- 
ly, reunited  and  fastened 
with  pins  and  sutures,  and  retained  in  position  by  drawing  the  de 


Fig.  481. — Dieffenbach's  method. 


PLASTIC    SURGERY. 


311 


tached  portions  of  the  cheeks  toward  the  median  line  of  the  nose, 
where  they  were  fixed  by  two  long  pins  passed  through  their  borders, 
under  the  nose.  In  this  instance  the  pins  were  passed  through  two 
narrow  strips  of  leather,  which  equalized  the  force  and  prevented 
the  producion  by  the  pins  of  premature  ulceration.  A  quill  sur- 
rounded by  oiled  lint  was  then  introducd  into  each  nostril.  The 
accompanying  figure  illustrates  the  proceeding,  with  its  result  (Fig. 
481). 

Superimposed  superficial  flaps  were  successfully  employed  by  Ver- 
neuil.     In  this  case  the  alas  and  tip  of  the  nose  were  uninjured,  but 


t 


Fig.  482. — Yerneuil's  method. 


were  flattened  by  loss  of  the  support  of  the  septum.  He  made  a  longi- 
tudinal incision  along  the  median  line  of  the  nose  at  the  center  of  the 
depression,  and  a  transverse  one  extending  from  each  end  of  the  first 
to  just  beyond  the  contour  of  the  nose  (Fig.  482),  and  dissected  the 
flaps  freely  from  their  attachments.  An  oblong  flap  of  suitable  size 
was  then  raised  from  the  forehead,  its  pedicle  being  located  directly 
between  the  eyes  ;  this  flap  was  turned  downward,  bringing  its  raw 
surface  uppermost.  The  lateral  flaps  were  then  drawn  inward  and 
placed  upon  it  and  united  in  the  median  line. 

The  Indian  Method  (483). — This  was  at  one  time  the  prevailing 
method  of  operation  when  the  septum  and  a  large  proportion  of  the 
soft  parts  of  the  nose  were  absent,  and  was  employed  even  when  the 
lower  extremities  of  the  nasal  bones  had  sustained  a  loss.  The  tend- 
ency to  atrophy  and  sliding  down  of  the  flap  after  union  had  taken 
place,  accompanied  by  closure  <>f  the  nostrils  and  danger  to  the  life  of 
the  patient  from  the  operation,  caused  the  substitution  for  it  of  more 


312 


OPERATIVE   SURGERY. 


Fig.  483. — Indian  method. 


satisfactory  measures.     A  flap  was  made  from  the  integument  of  the 

forehead  of  the  same  shape,  but  of  one  fourth  larger  size  than  the 

gap  to  be  filled  ;  its  base  was 
half  an  inch  broad,  and  located 
between  the  eyebrows.  The  flap 
was  therefore  substantially  the 
shape  of  the  ace  of  spades,  and 
included  all  the  tissues  down  to 
the  periosteum  (Fig.  483,  a),  the 
stem  above  being  intended  to 
form  the  columna.  The  edges  of 
the  gap  were  freshened,  and  the 
flap,  with  the  raw  surface  un- 
dermost, was  twisted  on  its  ped- 
icle and  attached  to  the  mar- 
gins of  the  gap.  The  flap  was 
then  made  prominent,  b,  by  the 
aid  of  greased  plugs  introduced 
into  the  nostrils,  and  also  by 
drawing  the  cheeks  toward  the 
median  line,  where  they  were 
fastened  by  means  of  pins  passed 

through  them  beneath  the  nose.     The  tendency  of  the  flap  to  slide 

downward  has  been  combated  in  various  ways — such  as  connecting 

the  pedicle  with  a  longitudinal  incision 

at  the  side  of  the  nose,  the  attachment 

of  its  whole  length  to  a  newly  formed 

raw  surface  at  its  base,  and  grafting  the 

sharpened  pedicle  into  the  integument 

at  its  base. 

Italian  Method. — This  old  method 

has  many  virtues,  and,  were  it  not  for 

the  great  difficulty  of  keeping  the  parts 

in  position,  would  be  much  more  em- 
ployed.    The  flap  is  taken  from  over 

the  biceps,  with  its  apex  toward  the 

shoulder.     It  is  first  dissected  up,  and 

its  extremities  allowed  to  remain  at- 
tached, until  suppuration  is  established, 

when  the  proximal  end  is  separated  and 

the  dressing  continued  until  the  flap 

is  well  shrunken  and  the  under  surface 

cicatrized.     It  is  then  applied  to  the 

gap  after  the   borders  of  both   have 

been    freshened    (Fig.    484).      When  Fig.  484.-Italian  method. 


PLASTIC   SURGERY. 


313 


union  is  completed,  the  pedicle  is  cut,  and  the  flap  is  fashioned  so  as 
to  relieve  the  deformity  in  the  best  possible  manner. 

Osteoplastic  Rhinoplasty. — The  periosteum  has  been  removed  fre- 
quently from  a  part  of  the  frontal  bone,  in  connection  with  the  flap, 
and  consigned  to  the  gap,  with  the  hope  that  the  formation  of  new 
bone  might  occur,  so  as  to  give  solidity  as  well  as  prominence  to 
the  new  nose.  The  removal  of  the  periosteum  from  the  frontal  bone  is 
not  by  any  means  devoid  of  danger.  Osteo-myelitis  has  arisen  there- 
from, followed  by  pyaemia  and  death.  The  periosteum  may  be  used 
to  form  a  portion  of  the  flap  first  applied,  in  the  double-flap  method, 
illustrated  in  Fig.  485.  It  is  true  that  the  relation  of  its  surfaces  will 
be  reversed,  but  this  can  not  change  its  bone-producing  value  ;  more- 
over, if  bone  be  formed,  it  can  be  easily  shaped  by  manipulation  to 
suit  the  proposed 
outline  of  the  or- 
gan. 

Ollier's  Meth- 
od. —  An  opera- 
tion was  per- 
formed some  time 
since  by  Oilier, 
for  a  deformity 
caused  by  the  loss 
of  the  alae,  co- 
lumna,  cartilages, 
lobe,  and  a  por- 
of   the  sep- 

due   to   lu- 
The    nose 

not     more 
an      inch 

due   to  ar- 
of    develop- 


Fig.  485.—  Ollier's  method. 


tion 

turn, 

pus. 

was 

than 

long, 

rest 

ment  of  the  ossa  nasi,  to  which  was  attached  a  strip  of  cartilage.     The 

integument  of  the  lip  and  cheeks  had  been  involved,  and  could  not 

therefore  be  depended  upon  for  flaps. 

Oilier  commenced  two  diverging  incisions  in  the  median  line  of 
the  forehead,  two  inches  above  the  eyebrows,  and  carried  them  down- 
ward to  a  fourth  of  an  inch  from  the  outer  hide  of  the  nasal  orifice 
(Fig.  485).  The  upper  portion  of  the  triangular  flap  included  the 
corresponding  portion  of  periosteum  down  to  the  upper  end  of  the 
nasal  hone-.  The  dissection  WSJ  continued  along  the  right  nasal  bone, 
omitting  the  periosteum,  down  to  its  lower  end,  from  which  the  car- 
tilage  waa  separated  ;  but  it  remained  attached  to  the  flap.  The  left 
nasal    hone   was   separated   from    its   bony  connections  with   a  chisel, 


314 


OPERATIVE   SURGERY. 


leaving  it  attached  to  the  flap  by  its  anterior  surface  ;  the  cartilagi- 
nous septum  was  then  divided  from  before  backward  and  downward 
with  scissors,  and  left  attached  by  its  base  to  the  cutaneous  cartilage, 
that  a  central  support  might  be  provided  for  the  new  structure.  The 
whole  flap  was  then  drawn  downward,  until  the  upper  border  of  the 
loosened  nasal  bone  (left)  came  opposite  to  the  lower  border  of  the 
right  one,  when  they  were  fastened  together  with  a  metallic  suture. 
The  sides  of  the  flap  were  then  united  to  the  cheek  and  the  frontal 
incision  closed  above  its  apex. 

In  this  case,  the  space  left  by  the  removal  of  the  left  nasal  bone 
was  filled  by  bone  developed  from  the  periosteum  that  had  been  slid 
down  from  the  forehead. 

This  variety  of  deformity  has  also  been  relieved  by  attaching  a  finger 
to  the  sides  of  the  nasal  chasm.  The  nail  was  first  removed  and  the 
palmar  surface  of  the  finger  was  denuded,  by  the  formation  of  lateral 
flaps,  down  to  the  distal  third  of  the  first  phalanx.  The  finger  was 
then  fastened  into  position  upon  the  freshened  borders  of  the  deform- 
ity, by  means  of  sutures  passed  through  the  lateral  flaps,  and,  when 
union  was  sufficient  to  sustain  the  nutrition  of  the  part,  the  finger  was 
amputated  at  the  juncture  of  the  middle  and  distal  thirds  of  the  third 
surgical  phalanx,  and  the  distal  end  turned  downward  to  form  the  end 
of  the  nose  and  its  columna. 

The  detail  essential  to  the  proper  description  of  this  operation, 
which  was  lately  done  with  success  by  Prof.  T.  T.  Sabine,  is  too  ex- 
tensive to  be  considered  here.  A  full  account  of  this  very  interesting 
case  can  be  found  in  the  April  number  of  the  "  Illustrated  Quarterly 
of  Medicine  and  Surgery,"  1882. 

Subcutaneous  Method. — This  method  consists  in  the  subcutaneous 
division  of  the  depressed  tissues,  so  that  they  are  separated  from  their 
bony  connections,  as  was  done  by  Prof.  Pancoast  in  1842,  and  can  be 
best  described  in  his  own  language  : 

"  A  long,  narrow-bladed  tenotomy-knife  was  introduced  on  either 
side  by  a  puncture  through  the  skin  over  the  edge  of  the  nasal  pro- 
cess of  the  upper  maxillary  bone.  The  knife  was  pushed  up  under 
the  skin  to  the  top  of  the  nasal  cavity,  and  then  brought  down, 
shaving  the  inner  side  of  the  bony  wall,  so  as  to  detach  the  ad- 
herent and  inverted  nose  upon  either  side.  The  point  of  the  nose 
could  now  be  brought  out.  The  nose  still  remained  adherent  to 
the  top  of  the  nasul  chasm.  The  knife  was  a  third  time  introduced 
under  the  skin,  in  a  direction  corresponding  nearly  to  the  long 
diameter  of  the  orbit  of  the  eyes,  and  the  adhesions  separated  from 
the  nasal  spine  and  the  internal  angular  processes  of  the  os  frontis. 
The  soft  parts  and  the  cheeks  were  loosened,  by  sweeping  the  knife 
outward  along  the  surface  of  the  bone,  so  far  as  to  divide  the  infra- 
orbital nerve  and  artery  on  each  side,  down  toward  the  median  line, 


PLASTIC   SURGERY. 


311 


Fig.  486. — Kingsley's  nasal  lever. 


and  held  together  with  sutures  passed  through  the  cavity  of  the 
nose." 

As  before  mentioned,  mechanical  appliances  can  be  employed  to 
support  the  soft  parts  of  the  nose,  provided  an  opening  exist  through 
the  roof  of  the  mouth.  Fig. 
486  shows  a  lever  sometimes 
employed  to  raise  and  sup- 
port the  parts  in  proper  posi- 
tion. 

In  this  instance,  however, 
the  lever  is  attached  to  an 
apparatus  intended  to  relieve 
an  additional  deformity. 
"  The  processes  E  E  pass  into 
the  nose,  and  support  the 
sunken  portion.  The  nasal 
elevator  must  be  so  arranged 
as  to  fall  back  of  the  line  B  B, 
to  be  introduced,    and   then 

must  extend  into  its  position.  This  is  accomplished  by  attaching  the 
elevator  to  the  denture  by  a  joint,  as  seen  in  the  engraving,  and  also 
by  extending  an  arm  of  the  elevator  within  the  shell,  and  terminating 
it  with  a  hook."  The  dotted  lines  show  the  lower  end  of  the  lever 
and  the  elastic  attachment  which  retains  it  in  position.  The  irritation 
consequent  upon  the  pressure  of  the  lever  is  not  severe,  and  can  be 
lessened  by  covering  the  ends  with  lint,  cerate,  etc. 

The  degree  of  elastic  tension  can  be  regulated  at  the  will  of  the 
patient,  and  even  be  entirely  removed  during  the  night. 

Hare-lip. — This  deformity  constitutes  a  large  proportion  of  the 
congenital  defects  calling  for  operations  upon  the  face. 

Operations  for  its  relief  can  be  performed  at  any  age,  but  the  bost 
time  is  as  soon  after  birth  as  the  infant  becomes  well  educated  to  take 
its  food  and  enabled  to  bear  the  loss  of  blood.  If  the  infant  be  plump 
and  robust,  it  can  be  performed  earlier  than  if  weak  and  puny.  The 
exceptions  are  rare  when  it  is  not  admissible  at  three  months  of  age. 
It  is  important  to  have  complete  control  of  the  patient  during  the 
operation.  For  this  purpose,  an  anaesthetic  should  always  be  given, 
chloroform  being  usually  selected.  The  arms  of  the  patient  are  placed 
at  the  sides,  and  are  held  in  position  by  a  napkin  surrounding  the 
body  and  pinned  sufficiently  tight  to  prevent  their  withdrawal. 

One  assistant  takes  the  child  in  his  lap,  while  another  stands  be- 
hind the  former  and  holds  the  infant's  body.  The  head  is  firmly 
held  between  the  hands  of  the  first  assistant,  so  that  he  is  able  not 
only  to  control  the  movements  of  the  head,  but  likewise  the  circu- 
lation in   the  facial  and  coronary  arteries,  and   to  bend   the  head  for- 


316 


OPERATIVE   SURGERY. 


ward,  that  blood  may  escape  from  the  mouth.  He  can  also  administer 
the  anesthetic  with  a  small  sponge  held  between  the  index-fingers. 
The  success  of  the  operation  will  depend  in  a  very  large  degree  upon 
the  entire  absence  of  tension  when  the  parts  are  placed  in  position. 
To  prevent  tension,  it  is  often  necessary  to  separate  the  lip  and  cheeks 
to  a  considerable  extent  from  their  bony  connections.  In  some  in- 
stances, owing  to  the  difficulties  of  the  case,  the  loss  of  blood  will  be 
considerable,  unless  every  precaution  to  prevent  it  be  taken.  The 
coronary  vessels  usually  supply  the  bleeding  points,  but  they  can  be 
easily  controlled  by  grasping  the  lip  at  both  sides  of  the  incision,  be- 
tween the  thumbs  and  fingers. 
By  this  procedure,  the  same  force 
that  puts  the  part  upon  the 
stretch  also  checks  the  flow  of 
blood.  The  fingers  of  the  as- 
sistant often  hinder  the  operator, 
especially  if  the  cleft  be  a  large 
one,  but  their  action  can  readi- 
ly be  supplemented  by  passing 
through  the  lip,  at  each  side  of 
the  proposed  cut,  a  strong  silk 
ligature,  which,  when  looped, 
makes  it  possible  to  keep  the 
parts  on  the  stretch  without  in- 
convenience. The  ligature  can 
be  so  placed  that  when  the  parts 
are  put  upon  the  stretch  the  cor- 
onary vessels  will  be  compressed. 
MJflf  ym  Either  Milne's  artery  compres- 

K  ll  sion  forceps  or  Langenbeck's  ser- 

K  fill         refines  (Figs.  55  and  58)  will  con- 

Jffff  YlH        trol  the  hemorrhage  admirably  if 

one  of  them  be  fixed  at  the  angle 
of  the  mouth  on  each  side.  If  the 
blades  of  the  ordinary  dressing 
forceps  be  surrounded  by  adhe- 
sive plaster  and  closed  upon  the 
lip  by  rubber  bands  passed  around 
the  handles,  a  useful  substitute 
will  be  had  for  the  instruments 
just  mentioned.  The  additional 
instruments  needed  are  a  strong 
pair  of  scissors,  two  scalpels- 
one  sharp  pointed— and  Butcher's  bone  pliers  (Fig.  487),  if  the  case 
be  complicated  with  a  projecting  intermaxillary  bone.     The  projecting 


Eig.  481.— Butcher's  bone  pliers. 


PLASTIC   SURGERY. 


317 


portion  may  be  pressed  into  position  often  by  direct  manual  force. 
A  liberal  supply  of  hare-lip  pins,  Buck's  needle-carrier  (Fig.  48),  silver 
sutures,  and  needles  and  needle-holder  are  required.  The  variety  of 
suture  to  be  employed  and  the  degree  of  tension  allowable  have  been 
already  considered  under  the  heading  devoted  to  that  purpose.  The 
borders  may  be  pared  with  a  sharp-pointed  scalpel,  strong  scissors,  or 
the  triangular  cataract-knife  ;  the  latter  is  a  very  useful  instrument 
for  this  purpose.  It  is  not  permissible  to  sacrifice  the  parings  taken 
from  the  free  borders  of  the  cleft,  except  in  cases  with  but  little  de- 
formity ;  they  should  remain  attached  and  be  utilized  in  filling  in  the 
gap,  this  being  the  only  satisfactory  manner  of  avoiding  the  occur- 
rence of  the  objectionable  notch  often  seen  after  operations  for  hare- 
lip. The  points  of  the  pins  should  perforate  the  flaps  at  least  a  third 
or  fourth  of  an  inch  from  the  borders  of  the  wound,  and  even  far- 
ther, if  there  be  any  degree  of  tension.  One  or  two  pins  will  be  suf- 
ficient in  the  majority  of  cases.  Neither  pins  nor  sutures  are  passed 
through  the  flaps,  but  are  passed  near  to  their  under  surface.  The 
sutures  may  be  inserted  nearer  to  the  edge  of  the  wound  than  the 
pins,  and  in  sufficient  number  to  properly  connect  its  lips.  The  latter 
are  removed  within  two  or  three  days  ;  the  former  may  remain  longer. 
If  ulceration  begin  around  the  pins,  they  should  be  removed  after 
others  have  been  inserted  at  new  points  to  receive  the  strain. 

Simple  Hare-lip. — This  variety  of  deformity  can  be  treated  by  paring 
and  uniting  directly  the  borders  of  the  cleft,  or  by  uniting  them  after 
incisions  extending  more  deeply,  which  likewise  sacrifice  the  borders  of 
the  cleft  (Fig.  488),  and  also  by  the  single  and  double  flap  method. 


Fig.  488. — Incisions  for  direct  union. 


The  simplest  method  consists  in  refreshing  the  borders  of  the  cleft, 
loosening  the  labial  connections  to  the  bones,  and  bringing  the  edges 
directly  into  contact.  Care  should  be  taken  to  secure  an  accurate  co- 
aptation of  their  vermilion  borders.  Unless  the  operation  is  carefully 
performed,  this  method  is  often  followed  by  a  notch  at  the  border  of 
the  lip  where  the  flaps  arc  joined. 

Sint/lr  Flu/)  (Fig.  489). — Draw  down  both  borders  of  the  cleft  and 
freely  .sever  their  connect  ions  with   the  bone  ;  pare  the  border  of  the 


318 


OPERATIVE   SURGERY. 


longer  portion,  c,  and  make  the  flap  on   the  shorter,  b  ;  approximate 
and  unite  them,  as  before  described. 

Double  Flaps.— -Pass  a  silk  ligature  through  each  angle  of  the 
fissure  (Fig.  490,  c) ;  divide  the  sublabial  connections,  make  one  side 


Fig.  489. — Single-flap  method. 


Figs.  490,  491.—  Double-flap  method. 


tense,  transfix  it  near  the  border  of  the  lip,  and  cut  upward  to  the 
apex  of  the  cleft ;  repeat  the  operation  on  the  opposite  side  of  the 
fissure  ;  draw  both  flaps  downward,  bringing  their  cut  surfaces  in 
contact  with  each  other  (Fig.  490,  d)  ;  close  the  cleft  with  a  pin  or 
suture  passed  near  to  the  vermilion  border,  and  insert  another  above 
if  necessary  ;  unite  the  everted  flaps  by  a  fine  silken  thread  or  horse- 
hair, e  ;  cut  off  their  extremities  obliquely,  leaving  enough  tissue  to 
form  a  permanent  projection  at  the  margin  of  the  lip,  in  order  to  ob- 
viate the  formation  of  a  notch.  If  the  cleft  be  shallow  (Fig.  491,  a), 
the  flaps  should  remain  connected  above  and  be  turned  downward  and 
united,  as  before  (Nelaton)  (Fig.  491,  b). 

Double  Flaps,  Giraldes'  Method. — This  method  is  principally  em- 
ployed only  when  the  deformity  extends  into  the  nasal  cavity,  and  the 
flaps  are  constructed  so  as  to  provide  a  floor  to  its  entrance  (Fig.  492). 


Figs.  492,  493.— Giraldes'  method 


When  the  flap  c  is  carried  upward  to  repair  the  floor  of  the  nostril,  the 
angle  of  the  cut  b  a  is  then  brought  in  contact  with  the  angle  of  the 
border  d,  and  their  cut  surfaces  are  made  of  a  similar  length.  The 
border  b  then  comes  in  contact  with  d,  and  the  point  of  the  flap  a 
rests  upon  the  undermost  cut,  in  which  position  they  are  united  (Fig. 


PLASTIC  SURGERY. 


319 


Fig.  494. — Double  hare-lip. 


493).  This  operation  is  an  admirable  one,  and  should  be  employed  on 
all  occasions  where  an  extensive  deformity  exists. 

Double  Hare-lip,  simple. — Pare  the  central  portion  (Fig.  494,  c) 
on  both  sides  ;  make  lateral 
flaps  with  their  attachments  be- 
low (Fig.  494,  a  b)  ;  liberate  the 
labial  attachments,  and  approx- 
imate the  raw  surfaces  by  the 
aid  of  pins  and  sutures. 

Complicated  Hare-lip. — Hare- 
lip  is  often   complicated  by  a 

fissure  through  the  alveolar  process,  which  sometimes  extends  to  the 
hard  palate,  and  even  beyond,  to  the  soft  parts.  For  a  time  before 
the  operation,  it  is  well  for  the  parents  or  nurse  to  make  gradual 
pressure  upon  the  more  prominent  bony  portion,  combined  with  out- 
ward traction  on  the  depressed  side,  endeavoring  thereby  to  cause  the 
alveolar  arch  to  assume  as  nearly  as  possible  a  normal  outline.  A 
reasonable  degree  of  patience  in  making  these  painless  manipulations 
will  in  time  effect  a  more  satisfactory  result  than  the  application  of 
sudden  force  by  means  of  forceps.  The  practice  of  forcing  the  alve- 
olar extremities  into  position,  paring  and  wiring  them,  is  a  pernicious 
one,  since  to  do  it  still  further  shortens  the  outline  of  the  arch  of 
mastication  of  the  superior  maxilla,  and  does  not  result  in  a  bony 
union  of  the  extremities.  The  gentle  but  constant  traction  exerted 
by  the  united  lip  will  in  time  as  certainly  reduce  the  bones  as  the 
more  vigorous  measures. 

It  is  better  to  allow  the  deformity  of  the  hard  parts  to  remain  un- 
molested until  the  teeth  appear,  when  the  outline  of  the  biting  surface 
of  the  upper  jaw  may  be  compared  with  that  of  the  lower  jaw,  and 
made  to  meet  it  by  rectifying  the  upper,  and  introducing,  if  neces- 
sary, additional  teeth  upon  a  plate  to  fill  the 
gap  in  the  biting  surface.     Giraldes'  method 
offers  the  best  opportunity  of  closing  the  fis- 
sures in  the  lip  in  these  cases. 

The  fissure  may  be  double,  and  involve 
both  the  hard  and  soft  parts,  back  to  and 
through  the  soft  palate.  The  intermaxillary 
bone  in  this  connection  may  project  freely, 
and  even  be  adherent  to  the  soft  parts  cover- 
ing the  end  of  the  nose  (Fig.  495).  If  such 
be  the  case,  after  the  division  of  the  vomer, 
or  the  removal  of  a  triangular  piece  from  the 
septum,  the  projecting  portion  is  forcibly 
pressed  into  position,  its  borders  refreshed, 
anr]  the  soft  parts  united,  as  in  the  simpler  forms ;  except,  perhaps, 


I  :<..  i'.)'>. — Complicated  hare 
lip. 


320 


OPERATIVE   SURGERY. 


it  may  not  be  prudent  to  unite  both  sides  simultaneously,  for  fear  of 
causing  too  great  traction. 

When  the  protruding  portion  is  connected  to  the  nose,  it  should  be 


Fig.  496. — Hainsley's  compressor. 


Fig.  497. — Operation  by  V-shaped  incision. 


separated  from  this  with  care,  or  the  columna  will  be  impaired.     The 
parings  are  utilized  in  correcting  the  upper  lip,  when  practicable. 

The  cheek-compres- 
sor, designed  by 
Hainsley,  may  be 
employed  to  hold  the 
parts  in  position 
when  the  conditions 
require  it  (Fig.  496). 
Cheiloplasty  is  an 
operation  directed  to 
the  restoration  of  de- 
formities of  the  lips 
dependent  on  dis- 
ease or  congenital 
defects. 

Deformity  of  Low- 
er  Lip,   V-Lncision. 
X     — This    incision     is 
employed  for  the  re- 
moval  of  epithelio- 
mata,  or  other  morbid  growths,  that  do  not  require  the  removal  of 


Fig.  498. — Celsus'  method. 


PLASTIC   SURGERY. 


321 


Fig.  499. — Cclsus'  method. 


more  than  one  third  of  the  lip.  The  whole  thickness  of  the  lip  is  di- 
vided ;  the  length  of  the  arms  of  the  V  being  increased  proportionate- 
ly to  the  width  of 
its  base.  The  usual 
liberating  incisions 
may  be  required, 
and  the  cut  sur- 
faces are  united  by 
the  same  mean;', 
and  cared  for  in 
the  same  manner, 
as  in  operations  for 
hare-lip  (Fig.  49?). 
Method  of  Cel- 
sius. —  When  the 
morbid  growth  in- 
volves the  whole  or 
half  of  the  lip,  the 
broad -based  V  in- 
cision is  supple- 
mented by  trans- 
verse ones  extending  outward,  from  each  angle  of  the  mouth,  a  suf- 
ficient distance  to  admit  the  easy  joining  of  the  V  borders  after  the 

tissues  have  been  freely 
liberated  from  their  bony 
attachments  (Figs.  498  and 
499).  If  difficulty  be  ex- 
perienced in  sliding  the 
flaps,  it  may  be  overcome 
by  making  short  vertical 
incisions  through  the  cheek 
at  the  outer  extremities  of 
the  horizontal  ones  (Fig. 
498,  e,  e).  The  most  in- 
genious feature  of  this 
method  consists  in  divid- 
ing the  buccal  mucous 
membrane  at  least  a  fourth  of  an  inch  above  the  incision  made 
through  the  cheek  and  parallel  with  it,  so  that  when  the  outward  cuts 
are  completed,  and  the  parts  joined  in  the  median  line  to  form  the  lip, 
its  raw  upper  borders  can  be  covered  by  turning  the  processes  of  mu- 
oona  membrane  OTer  them,  thereby  forming  an  excellent  vermilion 
border.  The  angles  of  the  mouth  are  also  to  be  formed  by  stitching 
the  membrane  and  buccal  cuts  to  each  other. 

Horizontal  Incision  (Fig.  500). — When  the  morbid  process  <l<>es 

2] 


Fig.  500. — Horizontal  incision. 


322 


OPEEATTVE   SUEGERY. 


Fig.  501.- 


-Syme's  method. 


not  involve  the  free  border  of  the  lip,  it  can  be  removed  by  an  oval 
incision,  and  the  gap  closed  in  the  usual  manner.     If  the  space  be  too 

large  to   admit  of 
closure,  it  can  be 
left     to     heal     by 
<\  granulation,  or  be 

»  remedied     by    the 

sliding  process, 
either  with  or 
without  parallel  or 
transverse  incis- 
ions. 

Syme's  Method 
(Fig.  501).  —  In 
this  method  the 
operation  is  per- 
formed by  contin- 
uing the  sides  of 
the  V  downward 
and  outward  in  a 
curvilinear  direc- 
tion for  about  two  inches,  dissecting  up  the  flaps  in  the  usual  man- 
ner, raising  them  up  to  form  the  lip,  uniting  them  in  the  median  line, 
and  allowing  the  remaining  portion  to  heal  by  granulation.  The 
mucous  membrane  should  then  be  stitched  to  the  integument,  to  pro- 
vide a  suitable  border.  Buchanan's  method  differed  from  Syme's  in 
making  the  extremities  of  the  flaps 
straight,  as  shown  by  dotted  lines 
(Fig.  501).  In  other  respects,  no 
radical  difference  exists  between 
these  methods. 

Buck's  Method. — He  first  re- 
moved the  morbid  growth  by  the 
V-shaped  incision,  and  united  the 
parts  in  the  usual  manner.  After 
union  had  taken  place,  the  short 
lower  lip  was  overhung  by  the  up- 
per, giving  to  the  patient  a  sucker- 
mouthed  appearance  (Fig.  502). 
The  steps  taken  to  relieve  this  de- 
formity can  best  be  described  in 
Dr.  Buck's  own  language  :  "In 
order  to  insure  precision  in  mak- 
ing the  requisite  incisions,  their  course  should  first  be  designated  by 
pins,  temporarily  inserted  erect  in  the  skin  at  certain  points,  as  shown 


Fig.  502.- 


-Operation  for  contracted  lower 
lip. 


PLASTIC   SURGERY. 


323 


by  Fig.  503.  Letters  a  a  represent  two  pins  inserted  at  one  finger's 
breadth  below  the  under-lip  border,  one  on  either  side  of  the  chin,  a  lit- 
tle to  the  outside  of  the  angle  of  the  mouth,  and  both  equidistant  from 
the  median  line  ;  b  b  are  also  two  pins  inserted,  one  on  either  side, 
into  the  upper  lip  at  the  margin  of  the  vermilion  border,  both  equi- 
distant from  the  median  line,  and  at  such  a  distance  apart  as  to  in- 
clude between  them  sufficient  length  of  lip  border  with  which  to  form 
a  new  upper  lip.  The  steps  of  the  operation  are  then  the  following  : 
with  the  forefinger  of  the  left  hand  placed  on  the  inside  of  the  mouth, 
the  cheek  is  held  moderately  on  the  stretch,  while  with  a  sharp-pointed 
knife  it  is  transfixed  at  the  point  a,  as  marked  by  the  lower  pin  in  the 
side  of  the  chin.  An  incision  is  then  carried  through  the  entire  thick- 
ness of  the  cheek  upward  and  a  little  outward  a  distance  of  one  inch 
and  a  half  to  a  point  c,  near 
the  middle  of  the  cheek.  The 
upper  lip  should  next  be  trans- 
fixed at  the  point  b,  marked 
by  a  pin  on  the  vermilion  bor- 
der, and  the  incision  carried 
through  the  lip  and  cheek 
outward  and  a  little  upward 
to  join  the  first  incision  at  its 
terminus  c  in  the  middle  of 
the  cheek.  A  triangular 
patch,  b,  c,  a,  will  thus  be 
formed,  which  will  include 
the  entire  thickness  of  the 
cheek,  with  its  apex  free  and 
disconnected,  while  its  base 
remains  attached  toward  the 
mouth.  The  next  step  is  to 
transfer  the  patch  from  the 
cheek  to  the  side  of  the  chin. 

For  this  purpose  an  incision  should  be  made  on  the  side  of  the  chin 
from  the  starting-point  of  the  first  incision  a,  vertically  downward 
to  the  edge  of  the  jaw  and  to  the  depth  of  the  periosteum  (Fig. 
503).  The  edges  of  this  incision  retracting  wide  apart,  afford  a 
V-shaped  space  for  the  lodgment  of  the  triangular  patch,  which 
is  now  to  be  brought  around  edgewise  and  adjusted  by  sutures  in 
the  new  location.  By  this  transfer  the  portion  of  the  upper-lip 
border  that  formed  a  part  of  the  base  of  the  patch,  is  brought  into  a 
transverse  line,  continuous  with  the  upper  lip,  and  forms  an  extension 
of  it.  The  space  upon  the  cheek  from  which  the  triangular  patch 
wta  taken  is  closed  by  bringing  its  edges  together  and  securing  them 
by  sutures.     By  this  adjustment  a  new  and  naturally  shaped  angle  is 


Fig.  £03. — Buck's  incision. 


324 


OPERATIVE   SURGERY. 


formed  for  the  mouth  at  the  point  b,  where  the  lip  was  transfixed  m 
commencing  the  second  incision  of  the  cheek.  The  incisions  must  be 
made  with  the  utmost  precision,  and  special  care  taken  that  the  mu- 


Fig.  504. — Malgaigne's  method. 


Fig.  505. — Sedillot's  method. 


cous  membrane  is  divided  exactly  to  the  same  extent  as  the  skin. 
The  same  procedure  may  be  applied  to  the  other  side  of  the  mouth 
and  executed  at  the  same  operation." 

Malgaigne's  Method  (Fig.  504). — The  growth  is  removed  by  means 
of  one  horizontal  and  two  vertical  incisions.  The  vertical  incisions 
begin  at  the  angles  of  the  mouth,  the  horizontal  one  is  located  between 
them  and  below  the  disease.     Two  additional  horizontal  incisions  are 

subsequently  made  on  each  side,  to 
permit  the  closure  of  the  gap  by 
the  sliding  method.  The  flaps  are 
freely  separated,  brought  forward, 
united  in  the  median  line,  and  the 
mucous  membrane  of  their  upper 
borders  stitched  to  the  integument. 
The  mucous  membrane  can  in  this 
instance  be  taken  with  the  cheek- 
flap  to  form  the  vermilion  border, 
as  in  Celsus'  method. 

Sedillot's  Method  (Fig.   505).— 

The  diseased  portion  is  removed  as 

in  the  preceding  method,  after  which 

Fig.  506. — Buck's  method.  the  vertical  incisions  are   extended 


PLASTIC   SURGERY. 


325 


Fig.  507. — Semicircular-flap  method. 


to  the  lower  border  of  the  jaw,  then  backward  far  enough  to  make 

flaps  of  sufficient  width  to  fill  the  gap  ;  thence  directly  upward  to  a 

point  opposite  the  angle   of 

the  mouth.     These  flaps  are 

dissected   up,   and  united  in 

the  median  line  by  the  usual 

means. 

Deformities  of  the  Upper 
Lip. — If  the  deformity  here 
be  slight,  it  can  be  remedied 
by  the  simple  means  employed 
upon  the  lower  lip. 

Intero-lateral  Flap  (Buck). 
— This  operation  was  done  to 
restore  one  half  of  the  upper 
lip  and  the  adjacent  portion 
of  the  cheek  (Fig.  506).  Di- 
vide the  under  lip  where  it 
joins  the  cheek  by  a  vertical 
incision,  a,  b,  at  right  angles 
to  its  border,  and  one  inch  in 
length.  Make  a  second  in- 
cision, b,  c,  one  inch  and  a 

half  in  length,  beginning  at  the  lower  end  of  the  first,  a,  b,  and  run- 
ning forward  parallel  with  the  border  of  the  lip.  An  oblique  incision, 
c,  d,  about  half  an  inch  in  length,  is  then  made  upward  and  forward 
from  the  end  of  the  horizontal  one,  leaving  the  flap  with  a  good  at- 
tachment at  this  point.  Pare  the  edges  of  the  deformity  and  the  end 
of  the  half-lip  above  ;  separate  the  half-lip  from  its  bony  attachments 
by  free  section  of  the  underlying  tissues  directed  upward  toward  the 
orbit ;  the  under-lip  flap  is  then  tipped  endwise,  and  its  upper  extrem- 
ity connected  by  sutures  with  the  end  of  the  upper  half-lip.  The  re- 
maining space  between  the  flap  and  the  cheek  is  closed  by  sutures. 
Fig.  512  shows  the  result  of  this  operation. 

Entire  Loss  of  the  Upper  Lip. — This  deformity  may  be  repaired  by 
semicircular  or  vertical  flaps. 

S> micircular-Flap  Method  (Buck). — Commence  an  incision  at  the 
median  line,  on  a  level  with  the  floor  of  the  nasal  cavity  on  each  side  ; 
carry  it  outward  and  downward  in  a  semicircular  manner  below  the 
lower  lip,  to  a  point  corresponding  to  its  middle  third,  a,  b  and  a,  c  (Fig. 
'<"', ).  These  incisions  are  to  be  carried  through  the  entire  thickness  of 
the  cheeks  and  lips  at  a  uniform  distance  of  an  inch  and  a  quarter  from 
the  border  of  the  opening.  Dissect  up  the  remaining  portions  of  the 
cheeks  freelj  from  their  attachments  beneath,  that  they  may  be  easily 
bronghi  forward.     The  upper  extremities  of  the  semicircular  flaps  arc 


326 


OPEKATIVE   SURGERY. 


trimmed  off  at  a  proper  angle,  e,  d,  after  which  they  are  united  in  the 
median  line  by  the  usual  means.  The  interval  between  the  cheeks 
and  the  newly  constructed  mouth  is  closed  by  sutures. 


Figs.  508,  509. — Sedillot's  vertical-flap  method. 


Vertical- Flap  Method  (Sedillot). — The  bases  of  the  flaps  in  this 
method  may  be  made  either  upward  or  downward,  the  former  being 

the  better  plan. 
They  should  com- 
prise the  entire 
thickness  of  the 
cheeks;  their  length 
and  width  corre- 
sponding to  the  di- 
mensions of  the 
proposed  new  lip, 
plus  the  one-fourth 
allowance  for  its 
shrinkage.  They 
are  carried  into  po- 
sition, and  united 
in  the  median  line. 
The  gaps  in  the 
cheek  may  be  closed  by  sutures,  or  allowed  to  heal  by  granulation. 
Dieffenoach's  Method.— 'Freshen  the  lower  border  of  the  remaining 


Figs.  510,  511.— Dieffenbach's  method. 


PLASTIC   SURGERY. 


327 


portion  of  the  original  lip,  then  raise  two  S-shaped  flaps,  one  at  each 
side  of  the  nose,  turn  them  across  the  space  in  front  of  the  alveolus, 
unite  them  to  each  other,  and  also  to  the  freshened  border  beneath  the 
nose  (Figs.  510  and  511). 

Stomatoplasty. — This  operation  is  employed  to  increase  the  size 
and  regulate  an  abnormally  shaped  mouth,  when  resulting  either 
from  disease  or  from  previous  operations. 

The  deformity  can  be  corrected  by  an  operation  already  described 
(Fig.  502),  when  the  lower  lip  is  the 
contracted  portion.  The  angles  of  the 
new  mouth  may  be  formed  by  means 
of  transverse  incisions,  made  at  the 
proper  situation.  Whenever  this  is 
done  the  mucous  membrane  must  be 
stitched  over  the  raw  surfaces,  to  pre- 
vent them  from  becoming  united  to 
each  other. 

The  operation  described  by  Buck 
for  restoring  the  angles  of  the  mouth 
is  simple  and  effective  (Fig.  512).  An 
incision  is  made  with  great  exactness 
along  the  line  of  the  vermilion  border, 
circumscribing  the  circular  half  of  the 
mouth,  and  extending  to  an  equal  dis- 
tance in  the  upper  and  lower  lips,  a  to 

b.  This  incision  should  only  divide  the  skin,  and  not  involve  the 
mucous  membrane.      A  sharp-pointed  double-edged  knife  is  inserted 


Fig.  512. — Stomatoplasty. 


Fig.  518. — Whitehead's  mouth-gag. 


Fio.  514. — Mason's  mouth-gag. 


328 


OPERATIVE   SURGERY. 


at  the  middle  of  this  curved  incision,  and  directed  toward  the  cheeks, 
flatwise,  between  the  skin  and  mucous  membrane,  so  as  to  separate 


Fig.  515. — Cheek-retractors. 


Figs.  516,  517.— Whitehead's 
forceps. 

them  from  each  other  as 
far  as  the  new  angle  of  the 
mouth  requires  to  be  ex- 
tended. 

The  skin  alone  is  next 
divided  outward  toward  the  cheeks,  on  a  line  with  the  commissure  of 
the  mouth,  d  to  c.     The  underlying  mucous  membrane  is  then  di- 


F  G  H 

-Lan<renbeck's  knives. 


Fig.  519. — Tenaculum. 

vided  in  the  same  line,  bat  not  so  far  outward.  The  angles  at  the 
outer  ends  of  the  two  incisions  are  accurately  united  by  a  single-thread 
suture.  The  freshly  cut  edges  of  skin  and  mucous  membrane,  above 
and  below,  that  are  to  form  the  new  lip-borders,  are  to  be  shaped  by 


PLASTIC   SUKGERY. 


329 


paring  first  the  skin,  and  then  the  mucous  membrane,  in  such  a 
manner  that  the  latter  shall  overlap  the  former  after  they  have  been 
secured  together  by  fine-thread  sutures  at  short  intervals. 

Operations  upon 
the  Palate. — The  op- 
erations emplo}-ed  to 
relieve  the  deformities 
of  the  hard  and  soft 
palate  are  denomi- 
nated staphyloplasty, 
staphylorrhaphy,  and 
uranoplasty.  The  in- 
struments required 
are  the  gag,  for  the 
purpose  of  holding  the 
mouth  well  opened 
(Figs.  513  and  514)  ; 
cheek-retractors  (Fig. 
515)  ;  seizing  forceps 
(Figs.  516  and  517)  ; 
variously  shaped 

knives  for  refreshing 
the  borders  of  the  de- 
formity (Fig.  518)  ; 
tenaculum  employed 
in  holding  the  flaps, 
etc.  (Fig.  519);  curved 
scissors  (Fig.  520)  ;  periosteotomes  (Figs.  521  and  522) ;  spiral  needle 


Fig.  520.— Curved 
scissors. 


Fig.  521.— Sayre's 
periosteotoine. 


Fig.  522.— Good- 
will's perios- 
teotonie. 


Fig.  523. — Whitehead's  spiral  needle. 


Fig.  524. — Sims'  suture-adjuster. 

OiHim* 
Fig.  525. — Sims'  wire-twisting  forceps. 





Fig.  526.  —  Goodwillic's  oral  saw. 


330 


OPERATIVE   SURGERY. 


for  sutures  (Fig.  523)  ;  suture-adjuster  (Fig.  524)  ;  forceps  for  twist- 
ing wire  sutures  (Fig.  525)  ;  oral  saw  (Fig.  526) ;  hoe  for  dividing  the 
muco-periosteal  membrane  (Fig.  527)  ;  sponges,  sponge-holders,  etc. 

Staphylorrhaphy  consists  in 
closing  an  abnormal  opening 
in  the  soft  palate  by  bringing 
its  freshened  borders  in  con- 
tact with  each  other.  The 
openings  vary  from  a  simple  cleft  of  the  uvula  to  a  complete  fissure 
of  all  the  soft  parts  (Figs.  528,  529,  and  530).     Some  time  prior  to 


Fig.  52*7.— Whitehead's  hoe. 


'%, 


J? 


Figs.  528-530. — Degrees  of  the  deformity. 


the  operation,  the  patient  should  be  instructed  by  manipulation  to 
control  properly  the  fauces,  so  that  the  surgeon  may  handle  the  parts 
without  causing  involuntary  movements  of  them.  If  the  fissure  be  a 
small  one,  it  can  be  closed  by  the  aid  of  a  solution  of  cocaine  with- 
out further  preparation. 

If  the  cleft  extend  through  the  whole  of  the  soft  palate,  even  en- 
croaching somewhat  upon  the 
hard  portion,  it  will  be  neces- 
sary, especially  if  the  gap  be  a 
wide  one,  and  the  muscles  con- 
trolling it  be  active,  to  destroy 
their  influence  before  attempt- 
ing to  unite  the  cleft.  The  ten- 
sor- and  levator-palati  muscles, 
together  with  palato-glossi  and 
palato-pharyngei,  are  the  ones 
that  exercise  contraction  on  the 
part,  and  if  they  be  properly 
severed,  the  velum  will  remain 
motionless  and  flaccid.  The  ac- 
companying illustration  shows 
their  relations  to  the  surround- 
ing parts  (Fig.  532). 

Fig.  531.— Freshening  the  borders.  The    palato-phai'VUgei    mus- 


PLASTIC   SURGERY. 


331 


cles  should  be  cut,  with  a  pair  of  blunt-pointed  scissors,  by  dividing 
the  posterior  pillars  of  the  fauces,  of  which  they  form  the  principal 
part.  The  palato-glossi  muscles,  comprising  the  anterior  pillars,  may 
be  cut  in  the  same  manner.  The  remaining  muscles  are  divided  after 
first  passing  a  silken  thread  through  the  velum  at  a  point  correspond- 
ing to  the  origin  of  the  uvula,  on  each  side  of  the  cleft ;  the  extremi- 
ties of  the  thread  are  looped  and  a  tenaculum  is  used  to  make  the  ve- 
lum tense,  while  the  following  muscles  are  divided  : 

Tensor  Palati. — Recognize  the  hamular  process  around  which  the 
tendon  tensor  palati  runs,  a  little  behind  and  internal  to  the  posterior 
molar  tooth.  Make  tense  that  segment  of  the  velum  by  the  suture 
just  introduced,  and  enter  the  point  of  a  narrow-bladed  knife  a  little 


Fio.  532. — Muscles  of  the  soft  palate. 


below  and  at  the  inner  side  of  the  process,  with  the  edge  upward  ; 
carry  it  upward,  backward,  and  inward,  until  the  point  Lfl  seen  through 


332 


OPERATIVE   SURGERY. 


the  gap  ;  this  divides  almost  the  entire  width  of  the  velum,  with  the 
main,  if  nob  the  entire  portion  of  the  tendon  of  the  tensor  palati. 

Levator  Palati.— Many  of  the  lowermost  fibers  of  this  muscle  will 
be  cut  by  the  preceding  incision.  If  a  greater  section  be  required, 
depress  the  handle  of  the  knife  and  carry  it  outward,  so  as  to  make  an 
oblique  incision  on  the  posterior  surface  of  the  velum  as  it  is  with- 
drawn. It  is  well  to  allow  two  or  three  days  to  elapse  before  attempt- 
ing the  union  of  the  cleft,  so  as  to  permit  hemorrhage  and  inflammatory 
action  to  subside,  and  to  determine  more  clearly  whether  further  sec- 
tion will  be  required.  This  muscle,  if  it  be  made  tense  by  drawing 
the  velum  toward  the  incisor  teeth  by  means  of  the  silken  thread,  may 
be  cut  with  blunt  scissors  under  direct  observation,  especially  if  the 
cleft  be  a  deep  one. 

Operation  of  Staphylorrhaphy. — There  are  three  steps  to  the  opera- 
tion of  staphylorrhaphy  :  1.  Freshening  the  edges  of  the  cleft.  2.  Pass- 
ing the  sutures.  3.  Coaptating  the  divided  borders,  and  tying  the  su- 
tures. First  apply  a  solution  of  cocaine  to  the  palate,  and  then  place 
the  patient  in  a  chair  which  will  permit  the  head  to  be  thrown  well 
back  so  as  to  expose  the  parts  to  a  strong  light.  The  lower  point  of 
the  cleft  is  then  seized  with  the  forceps,  made  tense, 
and  the  border  freshened  from  below  upward  (Fig. 
531),  or  the  reverse  if  desired.  Treat  the  opposite  side 
in  a  similar  manner. 

The  patient  is  allowed  to  rest  after  the  completion 
of  the  first  step,  until  the  hemorrhage  ceases  and  self- 
control  is  regained.  The  sutures  should  be  one  yard 
in  length,  and  doubled  before  passing,  and  thoroughly 
antiseptic.  Either  silk,  horse-hair,  silk-worm  gut,  or 
metallic  sutures  can  be  employed.  Three  or  four  are 
usually  sufficient.  The  first  should  be  introduced  at 
the  middle,  the  second  at  the  lower  extremity  of  the 
gap,  while  the  remaining  ones  close  the  spaces  between. 
They  can  be  passed  from  before  backward  on  one  side, 
and  from  behind  forward  on  the  other,  by  means  of  the 
needle-holder  and  the  ordinary  short-curved  needle 
(Fig.  533),  or  in  the  following  manner  by  means  of 
Whitehead's  spiral  needle  (Fig.  523).  Seize  the  left 
side  of  the  cleft  with  a  pair  of  forceps,  and  carry  the 
needle  through  it  at  the  point  selected  from  before 
backward  ;  draw  one  end  of  the  suture  through  between 
the  borders  of  the  cleft ;  withdraw  the  needle,  arm  it 
with  another  suture,  and  pass  it  on  the  opposite  side  in 
the  same  manner  ;  catch  the  thread  and  withdraw  the 
-Gross'  nee(ile,  leaving  the  looped  suture  in  the  border  of  the 
needle-forceps,     cleft  (Fig.  534) ;  then  pass  the  end  of  the  ligature,  first 


PLASTIC   SURGERY.  333 

inserted,  through  the  loop,,  which  is  then  drawn  out,  carrying  the 
siugle  thread  through  the  opposite  side. 

The  remaining  sutures  are  passed  in  a 
similar  manner.  Each  one  is  then  tied  some- 
what loosely,  to  allow  for  the  swelling,  with 
a  reef-knot,  or,  what  is  better,  the  slip-knot 
held  in  place  by  a  second  knot  over  it.  Per- 
forated shot  may  be  passed  over  the  sutures, 
and  held  in  position  by  compressing  them,  or 
by  the  ordinary  knot.  If  silver  wire  be  used, 
it  must  be  very  fine  and  flexible,  and  applied  Fig-  534.— Looped  suture. 
with  an  adjuster.  The  sutures  are  left  suf- 
ficiently long  in  either  case  to  admit  of  their  easy  removal,  which  is 
done  at  the  end  of  a  week.  The  diet  should  be  plain,  and  all  con- 
versation interdicted.  The  sponging  during  the  operation  must  not 
be  done  with  any  form  of  antiseptic  fluid  that  possesses  a  poisonous 
nature,  since  the  patient  may  swallow  a  certain  portion  of  it,  with  an 
unfavorable  if  not  an  unfortunate  result. 

Results. — The  prospect  of  union  of  the  parts  is  very  favorable, 
scarcely  more  than  five  per  cent  of  the  operations  being  failures.  The 
time  necessary  to  acquire  a  distinct  voice  is  variable,  and  often  this  is 
not  attainable. 

Uranoplasty. — This  operation  is  performed  to  close  a  fissure  in  the 
hard  palate.  It  should  not  be  attempted  on  a  patient  under  two 
years  of  age,  and  not  then  unless  the  patient  is  in  all  respects  in  per- 
fect health.  It  can  be  completed  at  one  sitting,  or  may  require  sev- 
eral, depending  on  the  obstacles  to  be  overcome. 

If  the  deformity  in  the  hard  palate  be  complicated  with  a  complete 
cleft  of  the  soft  palate,  each  one  should  be  treated  separately.  If, 
however,  the  cleft  of  the  soft  palate  be  partial,  it  can  then  be  operated 
on  at  the  same  sitting.  The  soft  portion  should  be  united  first,  in  the 
manner  before  described,  to  prevent  it  from  being  obscured  by  the 
blood  associated  with  the  operation  on  the  hard  palate. 

This  operation  consists  of  four  stages :  1.  The  paring  of  the  edges 
of  the  fissure.  2.  The  making  of  a  longitudinal  curvilinear  incision 
along  the  alveolar  process  close  to  the  teeth  (Fig.  535).  3.  The  rais- 
ing of  the  muco-periosteal  flaps  from  the  roof  of  the  mouth.  4.  Their 
union  along  the  median  line.  The  patient  is  ana3sthetized,  placed 
in  a  chair  facing  a  good  light,  the  gag  introduced,  and  the  first  step 
is  performed  easily  with  an  ordinary  knife  and  forceps.  The  flaps  are 
made  by  beginning  the  incision  at  the  posterior  border  of  the  last 
molar  tooth,  or,  more  practically,  in  front  of  the  hamular  process, 
and  carrying  it  down  through  the  periosteum  and  forward  along  the 
inner  margin  of  the  alveolar  process  to  the  line  of  junction  between 
the  lateral  and  middle  incisors.      If  the  curvilinear  incision  be  made 


334: 


OPERATIVE  SURGERY. 


incisors, 


at  the  base  of  the  alveolar  process,  or  be  carried  forward  to  the  central 
3  the  posterior  and  anterior  palatine  vessels  will  be  divided. 

These  flaps  are  now  to  be  carefully 
detached  by  a  peri  osteotome  from 
without  inward  and  from  before 
backward  until  the  edges  of  the  fis- 
sure are  reached  ;  they  are  then 
carried  toward  the  median  line,  and, 
if  no  degree  of  traction  be  noticed, 
united  throughout  to  each  other  by 
silver  sutures.  The  displaced  peri- 
osteum fills  in  the  gap  and  often  de- 
velops sufficient  bone  to  produce  an 
admirable  degree  of  firmness.  The 
sutures  are  allowed  to  remain  in  po- 
sition ten  days  or  two  weeks,  the 
patient  is  fed  on  liquid  food,  any 
cough  is  relieved  by  anodynes,  and 
the  parts  are  kept  clean. 

Langenbeck  closed  the  fissure  by 
two  flaps,  which  were  formed  by  an 
antero-posterior  division  of  the  hard 
palate  on  either  side  of  it  ;  fresh- 
ened their  contiguous  borders  and 
pushed  them  against  each  other  at 
the  median  line,  where  the  mucous  membrane  was  united  by  sutures, 
the  anterior  and  posterior  extremities  of  the  osseous  flaps  being  still 
connected  with  the  soft  parts. 

Ferguson  divided  the  hard  palate  with  a  chisel.  Mears  uses  Ad- 
ams' saw  after  drilling  an  opening  for  its  entrance,  and  claims  less 
injury  is  done  to  the  bone  than  by  any  other  means.  The  hemorrhage 
is  quite  severe  during  the  removal  of  the  periosteal  flaps,  but  it  is 
readily  controlled  by  pressure  and  cold.  When  the  osseous  flaps  are 
made,  the  bleeding  is  usually  still  greater.  If  the  fissure  be  not  in  the 
center,  the  flap  is  generally  taken  from  the  side  of  the  hard  palate 
which  has  the  greatest  width. 

Lannelongue  closed  the  opening  by  taking  a  properly  shaped  flap 
of  the  mucous  membrane  from  the  septum,  its  base  being  lowermost, 
and  stitching  its  upper  border  to  the  opposite  side  of  the  chasm. 

Mechanical  means  are  employed  to  fill  the  opening  in  the  hard 
and  soft  parts,  and  to  provide  even  an  artificial  uvula.  This  apparatus 
is  made  of  vulcanized  rubber,  and  is  held  in  position  by  being  attached 
to  a  plate  fitted  to  the  roof  of  the  mouth.  An  expert  dental  surgeon 
ought  to  be  consulted,  since  he  is,  as  yet,  the  only  one  fully  compe- 
tent to  treat  the  cases  by  this  method.     The  ability  to  speak  and  to 


Fig.  535. — Uranoplasty. 


OPERATIONS   OX   THE   MOUTII,   PHARYNX,    AXD   (ESOPHAGUS.      335 

otherwise  control  the  action  of  the  throat  and  pharynx  with  this  con- 
trivance is  very  satisfactory  ;  in  the  majority  of  instances  equaling, 
if  not  exceeding,  the  best  results  from  an  operation. 

Staphyloplasty  consists  in  filling  in  the  gap  of  the  soft  palate,  and 
as  much  as  possible  of  the  hard,  by  a  flap  taken  from  the  posterior  wall 
of  the  pharynx.  The  degree  of  success  attending  this  operation  is  suf- 
ficient to  warrant  its  adoption  when  the  conditions  demanding  it  are 
present. 

Operation. — Anaesthetize  the  patient,  perform  a  preliminary  tra- 
cheotomy, and  introduce  the  tampon-canula  into  the  trachea.  The 
flap  from  the  posterior  wall  of  the  pharynx  is  made  with  the  base  down- 
ward, and  the  apex  is  carried  as  far  upward  as  possible  to  permit  its 
introduction  into  the  cleft  without  the  least  tension.  The  width  and 
shape  of  the  flap  must  be  determined  by  the  size  and  outline  of  the 
deformity,  plus  its  normal  shrinkage.  It  should  consist  of  the  mucous 
lining  of  the  pharynx,  along  with  the  subjacent  muscles.  The  fibro- 
mucous  coverings  of  the  hard  palate  are  dissected  up  until  its  tissues 
and  those  of  the  velum  are  freely  movable.  The  borders  of  the  cleft 
are  freshened,  and  the  flap  brought  in  place  and  united  by  several 
sutures.  The  tampon-canula  can  be  removed  as  soon  as  hemorrhage 
has  ceased,  or,  at  the  farthest,  on  the  day  following  the  operation. 
The  parts  should  be  cleansed  frequently  and  carefully  with  a  mild  an- 
tiseptic fluid,  to  wash  away  the  abundant  secretions.  The  sutures 
should  be  removed  on  the  sixth  or  seventh  day  following  the  opera- 
tion. 

Elongated  Uvula. — An  elongated  uvula  is  easily  shortened  by  caus- 
ing the  patient  to  withdraw  the  tongue  by  aid  of  a  dry  towel  ;  seizing 
the  end  of  the  uvula  with  forceps  and  removing  the  required  amount 
with  scissors.  The  little  pain  that  may  be  caused  by  the  operation 
can  be  relieved  by  the  application  to  the  part  of  a  solution  of  cocaine. 


CHAPTER  XIII. 

OPERATIONS   ON  THE  MOUTH,  PHARNYX,   AND    ESOPHAGUS. 

Salivary  Fistula. — With  this  morbid  condition  the  saliva  is  dis- 
charged on  the  external  surface  of  the  cheek  instead  of  into  the 
mouth.  The  object  of  an  operation  is  to  establish  an  internal  com- 
munication so  that  the  external  opening  can  heal. 

The  cure  may  first  be  attempted  by  passing  the  ends  of  several 
long  silken  threads   through  the  external  opening  directly  into  the 


336 


OPERATIVE  SURGERY. 


Fig.  536. — Seton  in  position. 


mouth,  or  through  the  internal  opening  of  the  duct,  and  bringing  them 
out  at  the  angle  of  the  mouth  and  tying  their  extremities  (Fig.  536). 
The  internal  communication  is  easily  established  in  eight  or  ten  days  ; 

then  the  seton  can  be  removed  and  the 
borders  of  the  external  opening  freshened 
and  closed.  The  patient  should  be  ad- 
vised to  chew  upon  the  opposite  side 
during  the  healing  of  the  external  open- 
ing, to  limit  as  much  as  possible  the  flow 
of  saliva  on  the  diseased  side.  Another 
method  consists  in  passing  a  good-sized 
thread  of  silk  into  the  mouth,  through 
the  fistula,  from  without  inward,  and 
leaving  it  there  ;  removing  the  needle 
and  attaching  it  to  the  end  of  the  thread 
remaining  outside,  and  carrying  it 
through  the  tissues  into  the  mouth  in 
the  same  direction  as  the  former,  but 
not  exactly  in  the  same  track.  The  needle  is  then  removed,  and  the 
extremities  of  the  thread  are  firmly  tied  within  the  mouth.  A  fine 
rubber  ligature  can  be  substituted  for  the  silk.  The  loop  cuts  its  way 
through  the  tissues  grasped,  forming  an  internal  opening,  which  per- 
mits the  healing  of  the  external  one. 

The  method  recommended  by  Dr.  Horner,  which  is  employed  in 
obstinate  cases,  consists  in  the  introduction  of  a  wooden  spatula  into 
the  mouth,  opposite  the  site  of  the  fistula,  upon  which,  by  means  of  a 
saddler's  or  other 
suitable  punch,  the 
diseased  tissues,  duct 
and  all,  are  removed 
(Fig.  537).  The  ex- 
ternal opening  is 
closed,  a  cold,  dry 
dressing  is  applied, 
and  quiet  ordered. 
The  end  of  the  duct 
can  be  dissected  up 
and  passed  through 
a  small  incision  made 
through  the  mucous 
membrane  into  the 
mouth,   after  which 

the  external  opening  is  closed  (Van  Buren).  A  small  probe  should 
be  introduced  into  the  duct  from  without  to  prevent  it  from  being 
cut  during  the  dissection  ;  when  turned  inward,  the  borders  of  the 


<>lz*' 


Fig.  537. — Horner's  method. 


OPERATIONS   OX   THE   MOUTH,    PHARYNX,    AND   (ESOPHAGUS.      337 

open  extremity  can  be  confined  to  the  edge  of  the  incision  by  a  stitch 
of  catgut  or  horse-hair. 

Excision  of  the  Tonsils. — This  operation  can  be  done  with  an  or- 
dinary tenaculum  and  bistoury,  or  with  curved  scissors.  The  various 
forms  of  tonsillotomes,  while  they  simplify  the  operation  by  giving 
the  operator  a  perfect  control  over  the  cutting  edge,  are  not  necessary 
to  its  executiou. 

To  remove  the  Tonsil  with  the  Knife  or  Scissors. — If  the  patient 
be  young  or  unable  to  retain  self-control,  give  an  anaesthetic  or  apply  a 
strong  solution  of  cocaine.  Cause  a  bright  light  to  shine  into  the  open 
mouth,  depress  the  tongue,  seize  the  tonsil  with  the  tenaculum  or  for- 
ceps, draw  it  inward  from  between  the  pillars  of  the  fauces,  and  with 
scissors  curved  on  the  flat  or  the  probe-pointed  bistoury,  or  an  ordi- 
nary bistoury  with  the  point  guarded  by  adhesive  plaster,  sever  the 
gland  from  below  upward.  It  is  not  necessary  at  first  to  remove  the 
entire  tonsil,  since  a  curative  influence  is  often  established  by  its  incom- 
plete removal.  Among  the  forms  of  tonsillotomes  in  common  use  are 
Tiemann's  (Fig.  538),  Hamilton's  (Fig.  539),  Mackenzie's  (Fig.  540), 


539. — Hamilton's  tonsillotomc. 


and  others,  the  majority  of  which  combine  the  ability  to  seize,  hold 
up,  and  -ever  the  growth.     The  patient  is  placed  as  before  stated,  and 
22 


o3g  OPERATIVE   SURGERY. 

with  the  index-finger  the  ring  of  the  instrument  is  adjusted  around 
the  tonsil  properly,  and  the  tonsil  elevated  with  a  tenaculum,  and 


Fig.  540. — Mackenzie's  tonsillotome. 

severed  by  pressing  the  knife  against  it.  Any  undue  hemorrhage 
can  be  controlled  by  ice,  pressure,  and  astringents  ;  actual  cautery  is 
rarely  needed.  In  four  instances  the  internal  carotid  artery  has  been 
wounded  by  recklessness  in  cutting  the  tonsils. 

OPERATIONS    OS"   THE   TONGUE   AND    OESOPHAGUS. 

It  is  often  necessary  to  remove  the  tongue  in  part  or  entirely  on  ac- 
count of  hypertrophy,  and  malignant  and  other  growths  of  its  structure. 
The  arteries  supplying  it  are  the  dorsalis  linguas,  ranine,  and  branches 
from  the  ascending  pharyngeal.  The  ranine  is  the  principal  branch, 
and  runs  along  the  under  surface  of  the  tongue,  from  its  base  to  the 
apex.  The  buccal,  sublingual,  and  submaxillary  glands  are  closely 
associated  with  this  organ  in  a  surgical  sense.  The  facial  and  sublin- 
gual arteries  will  not  be  endangered,  unless  the  floor  of  the  mouth  is 
operated  upon  in  conjunction  with  the  tongue.  It  should  be  remem- 
bered that  the  circulation  in  the  opposite  sides  of  the  organ  does  not 
communicate  freely,  and  consequently  ligaturing  of  the  lingual  artery 
of  one  side  will  permit  of  free  incision  on  that  side  with  but  trifling 
hemorrhage. 

Tongue-tie. — This  condition  depends  on  an  undue  extension  for- 
ward of  thefraanum  linguae,  either  with  or  without  an  abnormal  short- 
ening of  it.  If  the  condition  be  severe  enough  to  call  for  treat- 
ment, the  end  of  the  tongue  is  pressed  upward  by  passing  the  first 
two  fingers  beneath  it,  palm  downward,  bringing  the  tense  frsenum 
between  them  on  the  palmar  surface,  when  it  can  be  divided  with  a 
blunt-pointed  scissors  at  a  little  distance  from,  but  parallel  with  its 
under  surface,  care  being  taken  not  to  sever  the  ranine  artery. 

Ranula. — The  closure  of  the  ducts  of  the  sublingual  and  other 
glands  in  this  situation  causes  a  cystic  distention  of  the  ducts,  and 


OPERATIONS   OX   THE   MOUTH,   PHARYNX,    AXD   (ESOPHAGUS.      339 

even  of  the  glands  themselves.  If  it  be  not  possible  to  find  and  probe 
the  duct-openings,  it  will  be  necessary  to  evacuate  the  contents  at  the 
floor  of  the  mouth  below  the  tongue,  or,  if  the  tumor  be  of  large  size, 
this  must  be  done  in  the  median  line  externally,  close  to  the  hyoid 
bone.  In  either  instance  it  may  be  necessary  to  pack  the  cavity  with 
lint  and  licpior  ferri  sulphatis,  or  cauterize  the  sack  with  nitrate  of 
silver,  and  even  to  dissect  it  partially  or  entirely  away. 

Excision  of  the  Tongue. — The  tongue  may  be  removed  with  the 
knife,  scissors,  galvanic  canter?/,  ecrasenr,  or  ligature.  The  last 
method  should  be  excluded,  as  the  time  required  and  the  pain  caused 
by  it  is  greatly  in  excess  of  that  by  the  other  methods.  If  the  diseased 
portion  be  small,  it  may  be  taken  away  by  the  form  of  incision  best 
calculated  to  accomplish  the  object,  since  it  is  not  a  good  plan  to  se- 
cure symmetry  at  the  expense  of  future  safety.  If  the  hypertrophy 
involves  the  apex,  or  if  a  tumor  be  located  at  this  situation,  it  can  be 
excised  by  removing  a  V-shaped  piece  in  the  following  manner  : 

Operation. — Anaesthetize  the  patient,  place  him  in  a  chair  in  a  strong 
light  with  the  mouth  well  opened  by  a  special  gag,  or  any  suitable  in- 
strument, forced,  with  a  string  attached,  between  the  posterior  molars. 
If  the  patient  be  in  the  recumbent  posture,  the  head  is  turned  to  one 
side,  to  collect  the  blood  in  the  hollow  of  the  cheek.  Pass  a  stout 
ligature  through  each  side  of  the  tongue,  just  outside  of  the  intended 
site  of  the  apex  of  the  V-incision  ;  loop  them  and  give  each  to  an  assist- 
ant with  instructions  to  pull  the  tongue  forward  ;  seize  the  tip  with  a 
pair  of  forceps,  or  between  the  thumb  and  finger,  and  with  a  sharp- 
pointed,  narrow-bladed  knife  transfix  the  organ  posteriorly  from  below 
upward  at  the  point  of  the  V,  cutting  outward  and  forward  through 
its  borders  ;  check  the  points  of  severe  hemorrhage  with  forceps,  and 
make  the  incision  on  the  opposite  side  in  a  reverse  direction  backward 


Fia.  541.— Removal  of  a  V-shaped  piece. 


Fio.  542.— Flaps  united. 


to  join  the  first  incision  (Fig.  541).     Ligature  the  bleeding  points  and 
unite  the  flaps  by  sutures  in  the  usual  manner  (Fig.  542).     A  method 


340 


OPERATIVE   SURGERY. 


has  been  recommended  by  Langenbuck  to  control  the  hemorrhage 
when  but  half  or  two  thirds  of  the  anterior  portion  of  the  tongue  is 
to  be  removed  by  cutting.  A  long,  well-curved  needle,  armed  with  a 
strong  ligature,  is  entered  at  the  left  of  the  median  line  of  the  tongue, 
behind  the  portion  to  be  removed,  and  passed  through  to  the  right 
side  and  under  surface  of  the  organ,  so  as  to  carry  the  ligature  beneath 
the  branches  of  the  lingual  artery.  The  ligature  is  then  carried 
through  the  right  border  of  the  tongue  and  firmly  tied.  A  similar 
procedure  is  repeated  on  the  opposite  side  of  the  tongue.  These  liga- 
tures can  then  be  used  to  draw  the  tongue  forward.  Dr.  Howe,  of 
this  city,  has  devised  a  "safety-pin  clamp,"  with  which  he  proposes 
to  control  the  hemorrhage  by  passing  the  pin  above  the  arteries  and 
screwing  the  clamp  into  position  against  the  intervening  tissues. 
Heath  highly  commends  the  drawing  of  the  stump  of  the  tongue  for- 
ward by  the  finger  passed  into  the  pharynx.  This  traction  not  only 
renders  the  bleeding  point  more  accessible,  but  the  hemorrhage  is  also 
directly  checked  by  means  of  the  pressure  necessary  to  draw  the  tongue 
forward. 

Hypertrophy  of  the  Tongue  (Fig.  543),  involving  its  entire  struct- 
ure, can  be  treated  by  the  re- 
moval of  a  V-shaped  piece  in 
the  manner  just  described. 
This  will  shorten  its  trans- 
verse diameter  and  diminish 
its  length.  The  flaps  are  then 
united,  and,  after  union  has 
taken  place,  the  thickness  of 
the  tongue  can  be  diminished 
in  the  following  manner :  A 
strong  ligature  is  passed  lat- 
erally through  the  organ  near 
to  the  base,  and  by  this  it  is 
drawn  forward  and  held  while 
a  wedge-shaped  piece  is  re- 
moved by  transfixing  laterally 
as  far  back  as  possible  and 
midway  between  its  upper 
and  lower  surfaces.  The  un- 
der flap  is  first  made  by  cutting  downward  and  forward  through  the 
under  surface  of  the  organ,  then  the  upper  flap  is  formed  by  applying 
the  knife  to  the  tissue  above  the  last  incision.  The  bleeding  points 
should  be  ligatured,  and  the  flaps  united  with  sutures. 

Half  of  the  organ  can  be  removed  by  first  ligating  the  lingual 
artery  corresponding  to  that  half,  after  which  two  long  stout  ligatures 
are  passed  through  it  near  the  tip,  one  on  each  side  of  the  median 


Fig.  543. — Hypertrophy  of  the  tongue. 


OPERATION'S   OX   THE   MOUTH,   PHARYNX,   AXD   (ESOPHAGUS.      341 


line,  by  these  the  tongue  is  drawn  forward  and  upward  ;  the  fraenum 
and  the  mucous  membrane  beneath  the  tongue  are  cut  with  scissors 
back  to  the  base  of  the  organ  ;  the  tongue  is  then  divided  in  halves, 
from  before  backward,  with  a  knife  or  scissors,  its  deeper  tissues  are 
separated  by  tearing  with  the  finger  or  handle  of  the  knife,  and  the 
portion  to  be  removed  is  finally  separated  with  scissors.  The  remain- 
ing half  can  be  removed  in  a  similar  manner.  If  the  lingual  arteries 
have  not  been  tied,  the  ecraseur  can  be  employed,  or  if  it  be  divided 
by  scissors  the  bleeding  points  should  be  secured  as  soon  as  possible. 

Removal  of  the  entire  Tongue. — This  can  be  done  either  through  the 
mouth  or  beneath  the  inferior  maxilla,  or  by  division  of  the  lower  jaw 
at  the  symphysis,  or  on  either  side  of  it.  It  can  be  removed  through 
the  mouth  by  the  knife,  scissors,  the  galvano-cautery,  or  the  ecraseur. 
When  the  knife  or  scissors  are  to  be  employed,  it  is  a  wise  precaution 
to  ligature  both  lingual  arteries  to  prevent  the  profuse  hemorrhage 
which  must  otherwise  occur.  A  stout  thread  is  then  passed,  through 
the  tongue  at  the  juncture  of  the  middle  and  anterior  thirds,  and  by 
this  the  organ  is  drawn  forward  and  upward,  and  detached  from  its 
connections  with  the  jaw  and  pillars  of  the  fauces.  The  muscles  of 
the  tongue  are  then  divided  by  scissors  back  to  near  the  larynx,  as 
closely  to  its  under  surface  as  the  disease  will  permit.  The  glosso- 
epiglottidean  folds  are  now  brought  under  control  by  passing  a  long 
ligature  through  each.  These  ligatures  are  allowed  to  remain  in  situ, 
in  order  that  the  floor  of  the  mouth  may  be  drawn  forward  by  them 
in  the  event  of  secondary  hemorrhage.  The  excision  is  then  com- 
pleted, and  all  bleeding  points  are  checked.  The  surface  is  permitted 
to  heal  by  granulation. 

Mr.  Whitehead,  of  Manchester,  has  frequently  operated  in  this 
manner  with  great  success, 
without  previously  ligating 
the  lingual  arteries,  but  by 
tying  the  bleeding  points  as 
they  presented  themselves. 
The  ecraseur  offers  an  ad- 
mirable means  of  removing 
the  whole  organ,  with  less 
danger  from  hemorrhage 
than  by  the  use  of  the  knife 
or  scissors  ;  the  results,  too, 
are  quite  satisfactory.  This 
instrument  maybe  applied 
through  the  mouth,  or  by 
way  of  a  free  puncture 
made  with  ;i  stout,  sharp-pointed  knife  introduced  from  without 
between    the   hyoid    bone   and   the   jaw,   a   little    nearer   the   latter, 


Fig.  644. — Ecraseur  in  position. 


342 


OPERATIVE   SURGERY. 


and  caused  to  enter  the  floor  of  the  mouth,  near  the  fcenum  (Fig. 
544).  The  wire  or  chain  is  passed  through  this  opening,  around  the 
base  of  the  tongue,  in  which  position,  after  the  tongue  is  well  drawn 
forward,  it  is  confined  by  means  of  three  or  four  stout  hare-lip  pins 
passed  at  short  intervals  through  its  base  from  side  to  side ;  after 
which  the  organ  is  slowly  and  carefully  severed.  If  the  tongue  be 
drawn  forward  in  the  usual  manner  and  freely  detached  from  its  con- 
nections with  the  jaw  and  floor  of  the  mouth,  the  same  instrument 
can  be  quite  as  readily  applied  without  the  submental  puncture.  The 
use  of  the  ecraseur  for  complete  ablation  can  be  recommended  with 
confidence  ;  and  it  should,  if  accessible,  be  selected  in  preference  to 
galvano-cautery,  which  is  much  more  likely  to  be  followed  by  second- 
ary hemorrhage. 

The  removal  below  or  through  the  jaio  does  not  offer  the  chances  of 
success  enjoyed  by  the  former  methods.  The  operation  devised  by 
Eegnoli  affords  easy  access  to  all  portions  of  the  tongue,  except  its 
base,  and  also  furnishes  good  drainage,  but  creates  a  large  and  some- 
what dangerous  wound. 

Operation. — A  crescen tic-shaped  incision  is  carried  along  the  base 

of  the  lower  jaw  (Fig.  545),  extending 
from  in  front  of  its  angles.  A  vertical 
incision  is  then  made  from  the  center 
of  this  to  the  median  line  of  the  hyoid 
bone.  The  flaps  are  reflected,  and  the 
attachments  of  the  lingual  and  hyoid 
muscles  divided  from  the  surface  of 
the  lower  jaw.  The  tongue  is  then 
drawn  through  the  opening  and  sev- 
ered by  the  knife  or  ecraseur,  the 
bleeding  points  being  secured  as  fast 
as  they  appear.  The  flaps  are  united, 
and  the  remaining  raw  surfaces  allowed 
to  heal  by  granulation. 

Knox  made  a  vertical  incision 
through  the  lower  lip  down  to  the  hyoid  bone,  extracted  a  tooth  and 
sawed  through  the  symphysis  mentis.  The  mucous  membrane  and 
the  muscular  attachments  of  the  tongue  were  then  divided,  the  lin- 
gual arteries  cut  and  tied,  and  the  tongue  removed  close  to  the  hyoid 
bone.  Mr.  Heart  employed  the  ecraseur  instead  of  the  knife.  Se- 
dillot  made  an  <-shaped  section  of  the  bone  to  prevent  the  frag- 
ments from  sliding  after  approximation.  Billroth  divided  the  jaw 
between  the  canine  and  last  molar  teeth,  corresponding  to  the  dis- 
eased side  of  the  tongue,  and  wired  the  fragments  after  the  removal  of 
the  diseased  portion. 

If  the  floor  of  the  mouth  be  involved  in  addition  to  the  tongue,  Bill- 


Fig.  545. — Regnoli's  incision. 


OPERATIONS   ON   THE   MOUTH,   PHARYNX,   AND    CESOPHAGUS.      3J-3 


roth  made  an  incision  about  one  inch  below  the  border  of  the  lower  lip 
from  one  facial  artery  to  the  other  ;  at  the  ends  of  this  incision  he  made 
two  vertical  ones  extending  to  a  point  about  four  fifths  of  an  inch  below 
the  border  of  the  inferior  maxilla  ;  at  the  juncture  of  these  vertical  incis- 
ions with  the  jaw,  he  divided  the  bone  and  turned  it  downward  along 
with  the  soft  parts,  thereby  affording  ample  room  to  reach  the  diseased 
parts  within.  If  the  portion  to  be  removed  be  extensive  and  the  danger 
from  hemorrhage  great,  a  preliminary  tracheotomy  is  advisable.  This 
measure  not  alone  prevents  the  blood  from  obstructing  respiration,  but 
lessens  the  dyspnoea  frequently  caused  by  a  wide  separation  of  the  jaws. 

Kocher  recommends  the  following  plan  if  the  floor  of  the  mouth, 
the  pharynx,  and  contiguous  glands  be  involved  along  with  the  tongue. 
After  a  preliminary  laryngo-tracheotomy  and  thorough  cleansing  of 
the  parts,  a  triangular  flap  is  made,  with  the  base  upward,  its  lower 
boundaries  corresponding  to  the  course  of  the  digastric  muscle,  and 
its  apex  being  at  the  point  of  connection  of  this  muscle  with  the  hyoid 
bone  (Fig.  5-iG,  c,  e,  cl,  b).  The  posterior  incision  may  also  be  made 
from  this  point  directly  to 
the  anterior  border  of  the 
sterno  -  mastoid  muscle, 
thence  upward  along  its 
border  to  the  angle  of  the 
jaw,  so  as  to  afford  a  greater 
space  than  is  afforded  by 
the  former  line  of  incision. 
These  flaps  cover  the  re- 
gion of  the  jaw  and  neck 
occupied  by  the  facial  ar- 
tery and  the  submaxillary 
gland  posteriorly,  and  the 
lingual  artery  and  sublin- 
gual gland  anteriorly.  The 
flap  is  dissected  up,  the  ar- 
teries are  tied,  and  the 
glands,  if  involved,  are  re- 
moved. This  exposes  the 
side  of  the  tongue  and  floor  of  the  mouth  for  easy  inspection  and  ma- 
nipulation. The  larynx  and  pharynx  are  then  protected  from  the  en- 
trance of  blood  by  a  large  sponge  to  which  a  string  should  be  attached, 
and  the  invo-hvoid  muscle  is  divided  close  to  the  jaw,  exposing  the 
tongue  freely.  The  organ  is  now  drawn  through  the  opening,  split,  and 
tin-  half  of  it  corresponding  to  the  flap  is  removed,  including,  if  neces- 

.  the  floor  of  the  mouth,  pillars  of  the  fauces,  and  pharynx  down  to 

the  hyoid  hone.  The  remaining  portion  can  be  removed  in  a  similar 
manner,  through  a  triangular  opening  on  the  Bide  corresponding  to  it,  or 


Via.  646. — Kochcr's  operation. 


344:  OPERATIVE   SURGERY. 

through  the  primary  opening,  if  the  extent  of  the  disease  will  permit. 
As  before  remarked,  the  operation,  which  involves  the  bone  and  soft 
parts  around  it,  results  less  favorably  than  when  the  tongue  is  re- 
moved through  the  mouth  by  the  methods  described  for  that  purpose. 
The  after-treatment  consists  in  keeping  the  mouth  cleansed,  while  to 
the  raw  surfaces  iodoform  and  iodoform  gauze,  or  other  suitable  anti- 
septic dressings,  are  applied.  The  tracheotomy-tube  should  not  be  re- 
moved until  all  dangers  from  inflammation  and  the  discharges  are  ended. 

Results. — The  rate  of  mortality  from  removal  of  the  tongue  by  all 
of  the  methods  described  is  considerable,  fixty-six  out  of  two  hundred 
and  forty-four  cases  having  died. 

(Esophagotomy. — It  sometimes  becomes  necessary  to  open  the  oesoph- 
agus on  account  of  obstruction  due  to  foreign  bodies  lodged  in  its  cer- 
vical portion.  In  this  connection  it  is  well  to  recall  the  relations  of  the 
oesophagus.  It  begins  opposite  to  the  cricoid  cartilage,  and  is  located, 
in  this  region,  somewhat  to  the  left  of  the  median  line.  The  situation 
of  the  foreign  body  is  usually  marked  by  a  greater  or  lesser  prominence 
on  the  left  side,  below  the  cricoid  cartilage  ;  or,  if  this  be  not  mani- 
fest, the  exact  site  of  the  canal  can  be  determined  by  the  introduc- 
tion into  it,  through  the  pharynx,  of  a  good-sized  bulbous  or  other 
form  of  probang.  The  following  are  the  important  surgical  relations 
of  the  oesophagus  in  the  cervical  region  :  In  front,  with  the  trachea, 
above,  and  with  the  thoracic  duct  and  the  thyroid  gland  below ;  be- 
hind, with  the  vertebral  column  and  longus-colli  muscle  ;  at  the  sides, 
especially  the  left,  with  the  common  carotid  and  inferior  thyroid  ar- 
teries, and  thyroid  lobes.  The  recurrent  laryngeal  nerves  lie  between 
it  and  the  trachea. 

Operation. — Always  employ  an  anaesthetic  ;  place  the  patient  on 
the  back,  with  the  chest  and  shoulders  elevated  and  the  head .  turned 
to  the  opposite  side  ;  feel  for  the  foreign  body,  and,  when  it  is  found, 
make  the  incision  directly  at  that  point. 

If  the  foreign  body  be  not  discernible,  make  an  incision  about  four 
inches  in  length  on  the  left  side,  between  the  sterno-mastoid  muscle 
and  the  trachea,  beginning  at  the  upper  border  of  the  thyroid  carti- 
lage. The  platysma  and  fascia  are  divided  on  a  director  ;  the  borders 
of  the  wound  are  separated,  the  omo-hyoid  is  drawn  outward,  and  the 
sterno-  and  thyro-hyoid  muscles  inward  ;  this  exposes  the  sheath  of  the 
carotid,  which  is  drawn  outward  and  retained  ;  the  lobe  of  the  thyroid 
gland  is  raised  and  drawn  inward ;  the  larynx  carefully  outlined  and 
drawn  forward  and  held  while  the  location  of  the  foreign  body  is 
sought  for ;  if  not  present  or  distinguishable,  the  bulbous  probang  is 
then  introduced  to  mark  the  outline  of  the  tube,  the  wall  of  which  is 
raised  with  a  tenaculum  and  opened  sufficiently  to  admit  the  finger, 
care  being  taken  to  avoid  the  recurrent  laryngeal  nerve.  The  site  of  the 
obstruction  is  located  by  passing  the  finger  into  the  tube,  and  the  cause 


OPERATIONS   0.\T   THE   MOUTH,   PHARYNX,   AND   (ESOPHAGUS.      345 

is  removed  by  suitable  forceps,  aided  by  manipulations  from  without, 
and  by  lengthening  the  incision  if  necessary.  The  opening  in  the 
oesophagus  may  be  closed  with  fine  catgut,  the  external  incisions 
united  in  the  usual  manner  and  dressed  antiseptically,  and  licpiid  food 
introduced  through  a  tube  for  a  few  days.  Or  the  entire  wound  may 
be  left  open,  a  feeding-tube  introduced  through  it  into  the  stomach, 
and  allowed  to  remain  three  or  four  days  at  a  time  ;  then  it  is  re- 
moved, to  be  cleaned.  As  soon  as  the  cut  surfaces  become  granulated, 
the  tube  may  be  removed  from  the  opening,  and  a  smaller  one  em- 
ployed, which  is  passed  into  the  stomach  through  the  nostril.  The 
patient  is  fed  through  this  until  the  oesophageal  opening  has  com- 
pletely closed. 

Fallacies. — The  foreign  body  may  be  mistaken  for  an  enlarged 
gland  on  external  examination.  The  oesophagus  may  be  confounded 
with  the  longus-colli  muscle  at  first ;  however,  a  moment's  examina- 
tion will  serve  to  dispel  the  doubt.  If  the  probang  be  introduced 
through  the  pharynx,  its  exact  location  will  be  established.  The  re- 
spiratory movements  of  the  oesophagus,  distending  and  collapsing 
alternately,  are  important  aids  in  determining  its  identity. 

Results. — Eighty-two  cases  are  reported,  of  which  nineteen  died  ; 
but  from  causes  independent  of  the  operation  in  many  instances.  The 
rate  can  be  placed  at  about  twenty-two  per  cent,  which  will  surely  be 
lessened  in  the  future  if  the  operation  be  done  as  early  as  it  should  be. 

Stricture  of  the  (Esophagus. — This  condition  depends  upon  a  cir- 
cumscribed inflammatory  action  or  other  morbid  process,  involving  one 
or  more  coats  of  the  tube,  and  causing  a  narrowing  of  its  caliber,  which 
manifests  itself  proportionately  to  the  degree  of  constriction.  It  may 
be  limited  to  one  side,  or  involve  the  whole  circumference  of  the  tube. 
The  most  frequent  site  is  opposite  the  cricoid  cartilage,  where  the 
pharynx  and  oesophagus  become  continuous  with  each  other.  The 
stricture  can  be  treated  by  dilatation,  for  which  purpose  various  forms 
of  dilators  have  been  constructed  (Fig.  547).     These  and  all  other 


F10.  517. — Oesophageal  dilators. 

forms  should  be  introduced  as  often  as  necessary  by  extending  the 
neck  and  passing  the  instrument  carefully  downward  in  contact  with 
the  posterior  portion  of  the  pharynx,  guided  by  the  index-finger  of 
the  disengaged  hand.  No  force  should  be  employed,  for  fear  of  causing 
a  false  passage.    The  surgeon  should  always  eliminate  the  possibility 


346 


OPERATIVE   SURGERY. 


of  aneurysmal  constriction  of  the  tube  before  an  attempt  is  made  to 
overcome  the  obstruction.     The  sponge  extremity  of  the  probang  can 
be  used  where  uuusual  caution  is  desirable  in  explor- 
r\        |\  ing  this  passage. 

\\      1 1)    ()  Retrograde  Divulsion. — In  1883  Loreta,   of  Bo- 

logna, opened  the  stomach,  passed  a  divulsor  through 
the  opening  into  the  lower  third  of  the  oesophagus, 
and  ruptured  a  stricture  at  this  point  sufficiently 
to  allow  the  passage  of  food.  He  has  since  repeated 
the  operation  on  two  occasions,  and  in  each  case  it  was 
followed  by  satisfactory  results. 

Internal  (Esopliagotomy. — This  operation  is  per- 
formed by  an  appropriately  constructed  instrument 
(Fig.  548),  sometimes  so  arranged  as  to  be  passed 
upon  a  guide,  as  in  internal  urethrotomy,  and  has 
been  successfully  practiced  on  several  occasions.  How- 
ever, the  contiguity  of  important  anatomical  "struct- 
ures, and  the  inability  to  comprehend  the  exact  re- 
lations of  the  stricture  to  the  outer  wall  of  the  tube, 
make  the  operation  an  exceedingly  hazardous  one. 
If  it  be  attempted,  the  constriction  should  be  incised 
only  sufficiently  to  admit  a  bougie,  by  the  means  of 
which  the  treatment  should  be  continued. 

Strictures  of  the  cervical  portion  of  the  oesopha- 
gus may  be  divided  from  without.  The  stricture  is 
first  located  by  a  bougie  introduced  into  the  tube, 
and  is  then  cut  down  upon  through  an  incision  simi- 
lar to  that  for  oesophagotomy. 

Results. — Internal  oesophagotomy  has  been  per- 
formed, in  all,  about  nineteen  times,  of  which  one 
third  died  in  sixteen  days  from  results  associated 
with  the  operation.  Of  the  remainder,  three  are 
said  to  have  recovered,  while  the  others  survived 
for  a  period  from  one  month  to  several  years.  About 
one  third  of  the  cases  required  one  or  more  repeti- 
tions of  the  operation. 

(Esophagectomy. — (Esophagectomy  consists  in  ex- 
cising a  portion  of  the  cervical  oesophagus  through 
an  incision  made  in  the  same  manner  as  for  oesophagotomy,  for  the 
removal  of  a  cancerous  growth.  The  upper  end  of  the  lower  portion 
of  the  tube  is  then  raised  forward  and  united  to  the  wound  ;  thereby 
forming  an  opening  through  which  food  may  be  introduced  by  means 
of  a  tube. 

Results. — Only  five  or  six  cases  have   as  yet  been  reported.     In 
two  of  these,  life  was  prolonged  for  months  ;  the  remainder  died  soon 


y*' 


Fig.  548.— Sands' 
instrument  for 
internal  oesoph- 
agotomy. 


OPERATIONS   ON   THE   MOUTH,   PHARYNX,   AND   (ESOPHAGUS.      34.7 

after  the  operation.  There  is  reason  to  believe  that  life  can  be  more 
prolonged  by  feeding  through  a  tube  in  the  usual  manner,  than  by  this 
procedure. 

(Esophagectomy. — This  procedure  is  employed  to  establish  a  fistu- 


FlG.    549.— Bris- 
tle piobang. 


Fi«.  550. — Sponge  and 
bucket  probang. 


Fig.  551. — disco's  tlnoat- 
forceps. 


Ions  opening,  with  the  tube,  below  the  point  of  an  incurable,  impassa- 
ble constriction.  It  provides  for  the  introduction  of  food  into  the 
stomach,  and  serves  as  a  temporary  palliative  measure. 

/,•  nils. — It  has  been  performed  thirty-two  times,  in  which  about 
-\\w  per  eenl  of  the  patients  perished.  Of  this  number,  twelvedied 
from  the  operation  directly  or  from  its  sequels. 

The  removal  of  foreign  bodies  from  the  o:sophagus  is  accomplished 


348 


OPERATIVE   SURGERY. 


Fig.  553. — Burge's  throat-forceps. 

by  probangs  (Figs.  549  and  550)  and  various  forms  of  long  forceps 
(Figs.  551,  552,  and  553). 


CHAPTER  XIV. 

OPERATIONS  ON  HOLLOW  VISCERA  IN   CONTACT  WITH  SEROUS 

SURFACES. 

The  injuries  of  these  organs  which  require  surgical  treatment 
may  result  either  from  external  violence,  or  become  part  of  the  pro- 
cedure necessary  for  the  removal  of  obstructions  in  the  intestinal  tube, 
or  of  malignant  growths  from  the  duodenum,  stomach,  or  intestines. 
In  these  operations  it  is  important :  1,  to  avoid  all  unnecessary  hem- 
orrhage ;  2,  to  prevent  the  escape  of  irritating  matter  into  the  abdom- 
inal cavity  ;  3,  to  unite  the  divided  surfaces  so  that  they  shall  remain 
properly  opposed,  and  be  followed  by  perfect  union  ;  4,  to  avoid  all 
unnecessary  shock  and  septic  or  irritating  influences.  The  first  indi- 
cation is  met  by  carefully  avoiding  any  incisions  through  the  line  of 
the  established  course  of  vessels,  and  by  the  use  of  needles  which  do 
not  possess  cutting  edges  (as  when  their  points  somewhat  resemble  those 
of  the  ordinary  sewing-needle),  but  enter  the  tissues  by  causing  their 
separation.  To  meet  the  second  indication  requires  a  great  degree  of 
caution  irrespective  of  the  knowledge  of  any  established  measures.  The 
lips  of  the  wound  should  always  be  kept  uniformly  and  well  raised  by 
means  of  forceps ;  or,  by  strong  ligatures  passed  through  their  bor- 
ders at  suitable  situations.  If  the  nature  of  the  case  will  permit,  the 
contents  of  the  viscus  should  be  removed  before  the  operation  is  com- 
menced, and  at  all  times  the  serous  surfaces  must  be  protected  from  con- 
tact with  irritating  matters,  by  means  of  broad,  thin,  antiseptic  sponges 
or  other  suitable  agents  moistened  in  a  warm,  mild,  antiseptic  fluid. 

To  fulfill  the  third  indication,  sutures  of  various  forms  and  meth- 
ods of  application  are  employed  ;  the  aim  of  all  being  to  bring  the 
serous  surfaces  in  contact,  and  maintain  them  so  until  firm  union  is 


HOLLOW  VISCERA  IN  CONTACT  WITH  SEROUS  SURFACED. 


349 


Fig.  554. — Lcmbert's 
suture. 


established.  To  do  this,  it  is  necessary  to  roll  the  borders  of  the 
wound  inward,  since  the  mucous  surfaces  will  not  unite  to  each  other 
(Fig.  554).  The  size  of  the  wound  has  to  do  with  its  treatment.  If 
it  be  of  large  size,  it  may  be  advisable  to  connect  it  with  the  opening 
in  the  abdominal  walls,  and  allow  the  resulting 
fistulous  opening  to  close  spontaneously.  When 
it  is  possible,  however  small  the  wound  of  the 
intestine  may  be,  it  should  be  closed,  or  it  may 
permit  the  escape  of  irritating  matters  into  the 
abdominal  cavity.  Tlie  fourth  indication  is 
very  important,  especially  if  the  operation  be 
prolonged  and  tedious,  or  if  the  intestines  be 

removed  from  the  cavity  of  the  abdomen.  The  room  in  which  opera- 
tions on  the  abdominal  contents  are  performed  should  be  thoroughly 
cleansed  and  fumigated  when  possible,  and  in  every  way  made  aseptic. 
If  its  temperature  can  be  raised  to  about  90°  F.,  and  the  atmosphere 
moistened  with  antiseptic  vapors,  the  surroundings  will  be  much  im- 
proved, especially  if  the  abdominal  contents  are  long  exposed.  If  the 
intestines  be  removed  from  the  cavity,  they  must  be  surrounded  by 
cloths  saturated  with  antiseptic  fluids,  and  kept  warm  and  moist  by  re- 
peated applications  of  the  same  until  they  are  replaced.  The  "  toilet " 
of  the  abdominal  cavity  must  be  cautiously  and  perfectly  made  before 
it  is  closed,  and  suitable  provisions  for  drainage  established,  if  per- 
nicious secondary  local  processes  be  apprehended.  As  a  rule,  the  su- 
tures should  not  include  the  mucous  surface,  but  should  extend  down 
to  it.  They  should  not  be  more  than  two  lines  apart,  nor  include 
more  than  one  line  of  the  intestinal  substance,  and  should  be  cut  short. 

Continuous 
Suture.  —  The 
name  defines  its 
method  of  ar- 
rangement. It 
is  exceedingly 
useful  in  join- 
ing the  borders 
of  long  cuts  of 
either  a  serous 
or  cutaneous 
surface.  In  the 
latter  the  stitch- 
es are  further 
apart  than  when 
applied  to  se- 
rous surfaces,  and  the  cut  surfaces  of  the  wound  are  brought  directly 
in  contact  with  each  other  (Figs.  555  and  80). 


Fro.  555. — Continuous  suture. 


Fro.  556. — Lcmbert's  suture. 


350 


OPERATIVE   SURGERY. 


Lemherfs  Suture  (Figs.  554  and  556).— This  form  of  suture  is  an 
admirable  one,  easy  of  comprehension  and  of  application.     It  can  be 


Fig.  55V. — Gely's  suture,  external  appearance. 

used  indiscriminately  in  all  wounds  of  serous  membranes,  either  in  the 
continuous  or  interrupted  forms. 

Gely's  Suture  (Fig.  557). — In  this  variety  a  long  suture  is  selected 
and  armed  with  a  needle  at  each  end.  The  needles  are  inserted  near 
the  angles  of  the  wound,  about  two  lines  from  the  edges,  and  carried 
along  the  interior  of  the  bowel  for  a  sixth  of  an  inch,  then  brought 
out  precisely  on  the  same  level,  so  as  to  again  appear  on  the  peritoneal 
surface.  The  sutures  are  then  crossed,  the  right  needle  being  passed 
through  the  puncture  made  by  the  left,  and  conversely.     If  a  knot  be 

made  at  each  crossing,  slip- 
ping of  the  sutures  will  be 
prevented.  The  number  of 
the  crossings  will  vary  with 
the  size  of  the  cut.  By 
this  method  the  edges  of 
the  wound  are  thoroughly 
inverted  (Fig.  558),  and  all 
danger  of  extravasation  is 
prevented. 

Joiert's  Method. — When 
the  intestine  is  completely 
divided  transversely,  its 
lower  end  is  turned  or  tucked  in  for  a  short  distance,  the  upper  end 
pushed  within  it,  and  their  serous  surfaces  are  united  by  fine  sutures 
(Fig.  559).  It  will  be  necessary  to  separate  the  mesentery  from 
each  extremity  of  the  intestine  for  a  short  distance  in  order  to  per- 
mit the  coaptation  just  described   (Fig.   560).      If    the   mesentery 


I, 


-•■i 


r 


Fig.  558. — Gely's  suture,  internal  appearance. 


HOLLOW  VISCERA  IX  CONTACT  WITH  SEROUS  SURFACES.  351 


Figs.  559,  560. — Jobert's  method. 

be  separated  unnecessarily,   sloughing  of  the  intestine   is   likely  to 
occur. 

Czerny-Lembert  Suture. — Two  rows  of  sutures  are  employed  in 
this  method,  neither  of  which,  however,  is  passed  through  the  mu- 
cous membrane  (Fig.  561).     The  first  series  brings  the  edges  of  the 


Fio.  561. — Czerny-Lembert  suture. 
a.  Mucous  coat.  b.  Muscular  coat. 
c.  Serous  coat. 


Fig.  562. — Gussenbauer's  suture,  a. 
Mucous  coat.  b.  Muscular  coat.  e. 
Serous  coat. 


mucous  membrane  together  ;  the  second,  or  external  series,  unites  tbe 
serous  surfaces  of  the  bowel.  Owing  to  the  eversion  of  the  intestinal 
structures,  the  first  row  can  be  introduced  without  difficulty. 

Gussenbauer'i  Suture. — By  means  of  this  form  of  suture  the  mu- 
cous and  seroui  structures  of  the  intestine  may  be  brought  together 
by  one  suture  (Fig.  562).  However,  this  stitch  is  complicated  and 
somewhat  ted  ion-,  and  affords  no  additional  security  to  repay  for  the 
delay  and  difficulty  attending  its  use. 


352 


OPERATIVE   SURGERY. 


A 

7/1 


S: 


-In   /' 


0> 


* 


<0r~. 


/^^X'ir 


OPERATIONS   ON"   THE   STOMACH. 

It  sometimes  becomes  necessary  to  open  into  the  cavity  of  the  stom- 
ach in  order  to  remove  foreign  bodies,  or  to  establish  a  permanent 
communication  with  it  through  the  abdominal  walls,  for  the  purpose  of 
supplying  alimentation.  It  is  therefore  very  important  to  understand 
its  relations  to  the  abdominal  walls,  and  likewise  to  other  contiguous 
parts.  It  lies  principally  in  the  epigastric  and  left  hypochondriac 
regions.  Its  anterior  surface  is  directed  upward  and  forward,  and  is 
in  relation  to  the  diaphragm  and  the  under  surface  of  the  left  lobe  of 
the  liver,  and,  unless  empty  or  adherent  posteriorly,  comes  in  contact 
with  the  abdominal  walls  in  the  epigastric  region.     It  is  altered  in  its 

position  and  rela- 
tions by  the  act 
of  respiration,  de- 
scending with  in- 
spiration and  as- 
cending with  ex- 
piration ;  when 
empty,  it  retires 
posteriorly  and  is 
covered  by  the  left 
lobe  of  the  liver. 
The  convexity  of 
the  stomach  sel- 
dom rises  above  a 
line  extending  be- 
tween the  carti- 
lages of  the  ninth 
ribs.  The  trans- 
verse colon  lies  at 
its  lower  border 
when  the  stomach 
is  moderately  dis- 
tended. 

The  identity  of 
the  stomach  is  es- 
tablished by  the 
knowledge  of  its 
relation  to  the 
under  surface  of 
the  liver  and  dia- 
phragm, by  its  pale 
color  and  great 
size,  and  by  the  arrangement  of  the  gastro-epiploic  vessels. 


~"^~Z~  —  - i 


4 


I 


Fig.  563. — a,  b.     Left  lobe  of  the  liver, 
the  stomach,      c.  Transverse  colon. 


i.  Cardiac  end  of 
Ascending  colon. 


d.  Descending  colon.     ff,ff,ff.  Sigmoid  flexure. 


HOLLOW  VISCERA  IN  CONTACT  WITH  SEROUS  SURFACES.  353 

Gastrostomy. — This  term  is  applied  to  the  operation  of  opening  the 
stomach  through  the  abdominal  wall  and  establishing  a  permanent 
fistula  to  it. 

Antiseptic  precautions  should  be  taken,  and  anaesthesia  produced 
by  chloroform,  as  ether  is  more  likely  to  cause  vomiting. 

Operation. — Place  the  patient  on  the  back,  and  make  an  oblique 
incision  on  the  left  side,  about  two  and  one  half  inches  in  length,  from 
right  to  left,  parallel  with  and  one  inch  below  the  lower  border  of  the 
cartilage  of  the  eighth  rib,  and  terminating  opposite  to  the  ninth  car- 
tilage (Fig.  503,  1).  The  tissues  composing  the  walls  corresponding  to 
this  incision  are  divided  successively  on  a  director,  down  to  the  perito- 
neum. All  bleeding  points  must  now  be  closed  and  the  peritoneum 
opened,  and  its  divided  borders  caught  and  drawn  outward  with  long 
ligatures,  or  forceps,  which  are  permitted  to  lie  on  the  external  surface, 
to  prevent  its  retraction.  The  lower  border  of  the  left  lobe  of  the  liver 
can  now  be  seen.  The  thumb  and  forefinger  of  the  left  hand  are  then 
introduced,  and,  guided  by  the  under  surface  of  the  liver,  readily  grasp 
the  stomach.  If  possible,  a  portion  of  it  should  be  brought  through 
the  opening,  or,  guided  by  the  thumb  and  finger,  forceps  may  be  in- 
troduced and  its  anterior  surface  grasped  and  drawn  through  the  open- 
ing. It  is  very  important  at  this  time  to  be  certain  that  the  portion 
drawn  through  be  not  the  colon  or  some  other  organ.  The  dense 
white  appearance  of  the  stomach,  the  arrangement  of  its  superficial 
vessels,  and  its  size  should  serve  to  distinguish  it  from  any  other  vis- 
cus.  Often,  as  soon  as  the  peritoneum  is  divided,  the  entrance  of  air 
into  the  abdominal  cavity  causes  the  stomach  to  retire  upward  and 
backward,  thereby  interposing  an  annoying  obstacle  to  grasping  it.  To 
obviate  this  difficulty  it  has  been  recommended  to  pump  air  into  the 
stomach  just  before  the  beginning  of  the 
operation  through  a  tube  carried  down  to 
the  obstruction,  or  to  cause  the  entrance 
of  carbonic-acid  gas,  produced  by  chemical 
action  at  the  time,  or  to  introduce  the 
fumes  of  ether  by  means  of  a  tube.  These 
expedients  are,  however,  hardly  of  sufficient 
practical  importance  to  merit  the  trouble 
incident  to  their  utilization. 

As  soon  as  the  surgeon  is  satisfied  that 
the  stomach  is  within  his  gvasp,  it  is  drawn 
into  the  opening  and  fixed,  by  passing 
through  it  in  opposite  directions  two  or 
three  long  stiff  needles  (Fig.  504),  allowing     Fio.  664.— Needles  in  position. 

their  extremities  to  rest  upon  the  external  surface  of  the  abdomen; 
or,  a  strong  ligature  is  passed  through  thoceuterof  the  protruding  por- 
tion, ii  looped  and  given  to  an  assistant.     The  parietal  layer  of  peri- 
28 


354  OPERATIVE   SURGERY. 

toneum  previously  grasped  and  drawn  outward  should  now  be  care- 
fully stitched  with  antiseptic  silk  or  catgut  sutures  to  the  visceral 
layer  on  the  stomach,  being  careful  not  to  carry  the  sutures  entirely 
through  the  wall  of  the  stomach.  Still  further  security  is  given  to 
the  opposed  surfaces  by  putting  a  row  of  stitches  of  strong  antiseptic 
silk  through  the  whole  thickness  of  the  abdominal  walls,  and  also 
through  the  ce.'ous  and  muscular  walls  of  the  stomach.  Two  other 
stitches  may  be  introduced,  so  as  to  transfix  the  end  of  the  wound  only, 
care  being  taken  not  to  include  the  peritoneum.  Finally,  a  ligature 
is  passed  through  the  serous  and  muscular  walls  of  the  center  of  the 
exposed  portion  of  the  stomach  (if  this  was  not  done  in  the  first  in- 
stance), and  left  hanging  to  be  used  as  a  future  guide  to  opening  the 
organ  in  case  the  condition  of  the  patient  will  admit  of  four  or  five 
days  delay,  sufficient  to  permit  adhesive  union  to  take  place  between 
the  serous  surfaces.  If  not,  then  the  operation  should  be  completed  at 
once.  This  is  done  by  making  a  vertical  incision  about  half  an  inch  in 
length  through  its  coats  into  the  cavity,  care  being  taken  to  prevent  the 
escape  of  its  contents,  If  troublesome  hemorrhage  be  apprehended 
from  this  incision,  the  opening  can  be  made  by  a  thermo-cautery.  The 
wound  in  the  abdominal  wall  is  reduced  in  size  to  correspond  to  that 
of  the  stomach  by  stitches  carried  through  its  entire  thickness.  The 
lips  of  the  opening  into  the  stomach  are  then  united  to  those  of  the 
abdominal  opening,  by  antiseptic  silk  carried  through  the  entire  thick- 
ness of  both,  being  careful  to  oppose  the  mucous  lining  of  the  stom- 
ach to  the  integument  of  the  abdomen. 

Fallacies. — The  colon  may  be  mistaken  for  the  stomach.  However 
the  difference  in  color,  extent,  and  muscular  arrangement,  together 
with  the  difference  in  mobility,  and  the  fixed  relation  of  the  stomach 
to  the  under  surface  of  the  liver,  should  make  the  distinction  easy. 
Confusion  may  arise  in  distinguishing  the  cartilage  of  the  eighth  rib 
from  the  contiguous  ones.  The  seventh  articulates  with  the  sternum  ; 
the  first  one  below  it  will  therefore  be  the  eighth. 

Other  external  incisions  differently  located  and  variously  shaped 
may  be  employed ;  such  as,  a  curvilinear  one  with  the  convexity 
toward  the  median  line,  extending  from  the  seventh  costal  cartilage 
downward  and  outward  for  nearly  four  inches,  one  through  the  left 
linea  semilunaris,  or  one  along  the  outer  side  of  the  rectus,  etc.  That 
which  has  been  described  in  detail  seems  the  most  favorable  from  an 
anatomical  basis. 

The  results,  however,  are  of  necessity  very  unfavorable,  since  the 
conditions  calling  for  the  measure  are  often  of  themselves  speedily 
fatal ;  moreover,  the  delay  in  resorting  to  it  frequently  renders  the  pa- 
tient unable  to  withstand  the  shock  of  the  procedure.  Two  hundred 
and  seven  gastrostomies  are  reported,  from  which  sixty-one  deaths 
have  resulted  directly.     In  about  one  hundred  and  seventy  of  the  whole 


HOLLOW  VISCERA  IN  CONTACT  WITH  SEROUS  SURFACES. 


355 


number  fifty  died  from  the  direct  effects  and  from  the  sequels  of  the 
measure,  making  a  death-rate  of  about  thirty  per  cent.  This  is  about, 
fourteen  and  a  half  per  cent  greater  than  when  the  operation  was  per- 
formed for  the  removal  of  foreign  bodies  alone.  When  due  to  malig- 
nant disease  it  only  acts  as  a  palliative  measure,  while  more  than  sixty 
per  cent  have  recovered  when  performed  for  non-malignant  cicatricial 
obstructions.  This  operation,  and  also  gastrotomy,  is  sometimes  em- 
ployed for  making  an  opening  into  the  stomach  to  remove  a  foreign 
body  which  has  entered  it  through  the  oesophagus.  The  line  of  in- 
cision, and  all  the  steps  and  precautions,  are  similar  to  those  for  gas- 
trostomy proper.  After  the  foreign  body  is  removed,  the  opening  in 
the  stomach  is  closed  by  catgut  sutures,  after  the  manner  of  intestinal 
sewing,  and  returned  to  the  abdominal  cavity,  and  the  opening  in  the 
abdominal  walls  closed.  The  patient  must  be  nourished  by  the  rec- 
tum, and  all  gastric  disturbances  quieted  by  anodynes. 

Gastroenterostomy. — This  is  essentially  a  palliative  operation,  and 
was  performed  first  by  Woelfler  in  1881,  since  which  time  it  has  been 
done  upward  of  twenty  times  for  advanced  pyloric  cancer  and  non- 
malignant  pyloric  stenosis.  When  performed  for  the  former  reason, 
about  sixty-four  per  cent  of  the  cases  have  died,  while  for  the  latter 
but  twenty-five  per  cent  have  died. 

All  the  antiseptic  precautions  that  surround  abdominal  surgery 
(gastrostomy,  enterectomy,  etc.)  should  be  observed. 

Operation. — An  abdominal  incision  is  made  in  the  median  line  from 
just  below  the  tip  of  the  ensiform  cartilage  downward  nearly  to  the 
umbilicus,  and  the  abdominal  cavity  is  entered  in  the  usual  manner. 
The  viscera  to  be 
united  (stomach  and 
jejunum)  are  caused 
to  present  at  the  ex- 
ternal opening,  where 
they  are  carefully  iso- 
lated from  the  abdom- 
inal cavity  and  pro- 
tected by  warm,  moist 
antiseptic  sponges. 
The  loop  of  intestine 
to  be  attached  to  the 
stomach  is  emptied  by 
gentle  pressure,  and 
the  intestinal  contents 
cut  off  from  it  by  the 
intestinal  pincers,  by 
the  fingers  of  an  assist- 
ant, or  by  strips  of  loosely  tied  iodoform  ized  gauze. 


Fig.  565. — Gastroenterostomy. 


The  stomach 


356  OPERATIVE   SURGERY. 

should  have  been  emptied  and  thoroughly  washed  out  with  a  salicy- 
late-of-soda  solution  before  the  operation.  An  incision  about  an  inch 
and  a  half  in  length  is  made  through  the  anterior  inferior  wall  of  the 
cardiac  half  of  the  stomach,  down  to  the  mucous  membrane  (Fig. 
565).  An  incision  of  a  similar  size  is  then  made  on  the  intestinal 
loop  down  to  its  mucous  membrane,  b.  The  lower  borders  of  the  cut 
surfaces  are  placed  in  contact  and  united  with  a  continuous  suture  of 
silk  or  catgut,  carried  from  without  inward  between  the  mucous  and 
muscular  coats  of  the  respective  viscera,  thereby  causing  the  borders 
of  similar  structures  to  be  brought  in  contact  with  each  other.  The 
mucous  coats  are  then  opened  by  scissors,  taking  care  to  prevent  the 
least  extravasation  into  the  abdominal  cavity.  The  remaining  por- 
tions of  the  borders  are  now  united  in  a  similar  manner  to  the  first, 
and  the  whole  circumference  of  the  wound  is  fortified  by  a  second 
row  of  either  the  continuous  or  interrupted  suture,  carried  through 
the  serous  coats  only. 

Duodenostomy,  or  the  formation  of  a  permanent  artificial  opening 
into  the  duodenum  through  the  abdominal  wall,  has  been  suggested 
as  an  alternative  to  pylorectomy.  It  has  been  performed  three  times, 
with  a  fatal  result  in  each  case.  It  is  not,  at  the  present  time, 
thought  to  be  a  justifiable  operation. 

Jejunostomy  has  been  recommended  as  a  substitute  for  pylorec- 
tomy. It  is,  no  doubt,  much  more  easily  performed  than  duodenos- 
tomy ;  but  the  advantages  in  favor  of  gastroenterostomy  are  too 
numerous  and  important  to  admit  of  its  being  superseded  by  either 
of  the  other  operations. 

Resection  of  the  Pylorus. — This  operation  has  been  quite  frequently 
employed  since  1879  to  relieve  obstruction  occurring  at  the  pylorus, 
due  to  malignant  disease,  and  stenosis  from  other  causes.  While  its 
inception  and  performance  are  in  keeping  with  the  rapid  strides  made 
in  abdominal  surgery  in  the  past  few  years,  the  nature  of  the  opera- 
tion and  the  causes  for  which  it  is  done  must  of  necessity  insure  a 
large  number  of  deaths.  The  pylorus  is  in  the  epigastric  region,  be- 
tween the  median  line  and  a  line  falling  from  the  tip  of  the  cartilage 
of  the  eighth  rib  on  the  right  side  to  the  middle  of  Poupart's  liga- 
ment, and  is  in  contact  with  the  under  surface  of  the  right  lobe  of 
the  liver. 

The  duodenum,  which  is  the  next  most  important  factor,  is  located 
in  the  right  hypochondriac  region,  being,  of  course,  a  direct  continua- 
tion of  the  pyloric  extremity  of  the  stomach.  The  normal  relations, 
however,  will  avail  but  little  in  connection  with  the  abnormal  size, 
and  the  displacement  attendant  upon  an  already  over-distended  stom- 
ach. All  primary  incisions  must  therefore  be  located  so  as  to  meet 
the  indications  of  the  case  in  question.  The  difference  in  the  outlines 
of  the  stomach  is  noted,  both  in  its  distended  and  empty  condition, 


HOLLOW   VISCERA    IN   CONTACT   WITH   SEROUS   SURFACES.       357 

to  better  enable  the  surgeon  to  properly  locate  the  abdominal  incis- 
ion. In  some  cases  the  greater  curvature  may  reach  the  symphysis 
pubis. 

The  patient  is  prepared  by  washing  out  the  stomach  daily  with  sal i - 
cylated  water  or  any  suitable  antiseptic  for  four  or  five  days  prior  to  the 
operation,  the  stomach-pump,  or  siphon,  being  employed  for  the  pur- 
pose. The  intestinal  canal  is  evacuated  the  day  before  the  operation. 
An  anaesthetic  is  given,  chloroform  being  preferable  as  less  likely  to 
produce  vomiting,  and  the  patient  is  placed  on  the  back  in  a  good 
light.  The  stomach  should  be  thoroughly  washed  out  before  begin- 
ning the  operation. 

Operation. — An  incision  is  made  about  four  inches  in  length  in 
the  median  line,  or  parallel  to  the  right  costal  margin  (Fig.  563,  2),  as 
nearly  as  possible  over  the  displaced  pylorus.  The  tissues  are  divided 
carefully  down  to  the  peritoneum,  and  all  bleeding  stopped  before  this 
membrane  is  divided  ;  an  exploration  with  the  finger  is  also  made, 
to  determine,  if  possible,  the  exact  location  of  the  indurated  portion, 
after  which  the  final  opening  is  made  to  correspond  to  it. 

If  it  be  impossible  to  satisfactorily  outline  the  organ,  it  may  be 
distended  with  fluid — which  must  be  withdrawn  when  the  location  of 
the  diseased  portion  is  determined — or  with  carbonic-acid  gas  ;  even 
the  fumes  of  ether  can  be  introduced  as  in  rectal  anaesthesia.  The 
peritoneum  is  cut,  and  the  pylorus  and  such  other  portions  as  are 
necessary  are  then  drawn  through  the  wound  and  isolated  and  sur- 
rounded by  napkins  or  large  flat  sponges  wrung  out  in  a  warm  anti- 
septic solution.  A  large,  flat,  soft  sponge,  moistened  with  an  anti- 
septic solution,  is  then  passed  beneath  the  part  to  be  removed,  to 
prevent  the  entrance  of  blood  and  other  fluids  into  the  abdominal 
cavity.  Strong  ligatures  may  now  be  passed  through  the  walls  of  the 
viscus  at  three  or  four  points  outside  of  the  proposed  incision,  so  as  to 
raise  the  walls  of  that  extremity  as  soon  as  it  is  divided,  that  its  con- 
tents may  not  escape. 

The  omenta  are  separated  the  necessary  distance  along  the  curva- 
tures of  the  stomach  by  tying  them  in  small  portions  and  dividing  them 
between  the  ligatures.  The  pyloric  extremity  of  the  stomach  is  then 
incised  writh  strong,  long-bladed  scissors  from  above  downward,  and 
from  left  to  right,  for  about  two  thirds  of  its  depth,  through  both 
walls,  at  a  point  at  least  two  thirds  of  an  inch  from  the  diseased  growth 
in  its  structure.  The  stomachal  borders  of  this  incision  arc  then 
joined  by  the  Czerny-Lembert  suture,  the  threads  being  located  about 
one-eighth  inch  apart.  The  pyloric  extremity  of  the  stomach  is  now 
cut  entirely  across,  and  the  resulting  opening  in  the  stomach  should 
correspond  in  its  extent  to  the  width  of  the  duodenum,  which  should 
now  be  cut  completely  across  in  the  same  manner  as  the  stomach.  The 
divided  extremity  of  the  duodenum  is  carefully  sewed  bo  the  opening 


358 


OPERATIVE   SUKGERY. 


in  the  stomach  by  the  Czerny-Lembert  suture,  or  such  other  form  of 
suture  as  may  suit  the  surgeon. 

The  diseased  growth  should  be  removed  with  great  care,  and  with 
due  regard  to  the  preservation  of  the  vascular  supply  of  the  viscera. 
Sloughing  of  the  gastric  or  duodenal  margin  of  the  wound  or  the  walls 
of  the  colon  caused  by  disturbance  of  nutrition  is  one  of  the  greatest 
dangers.  The  pyloric,  gastro-duodenal,  and  gastro-epiploica  dextra 
arteries  and  their  branches  should  be  preserved  for  this  reason,  when 
this  can  be  done,  and  the  removal  of  the  diseased  tissues  be  still  ac- 
complished. 

If  any  oozing  occur  from  the  cut  surfaces,  it  may  be  controlled  by 
the  protected  blades  of  the  T-shaped  pincers  (Fig.  566),  etc.  The 
extent  of  the  incisions,  as  well  as  their  shape,  will  be  governed  by 

the  diseased  tissue 
to  be  removed.  If 
adhesions  exist  be- 
tween the  growth 
and  the  contigu- 
ous parts,  they  can 
be  separated  if  ex- 

Fig.  566. — Cross-bar  forceps.  ,.       ,         .„  , 

pedient  ;  it  not, 
no  further  attempt  to  complete  the  operation  need  be  made,  and 
the  abdomen  should  be  closed.      The  respective  extremities  of  the 


Fig.  56V. — Abbe's  intestinal  pincers. 

divided  viscera  can  be  well  controlled  by  the  fingers  of  an  assistant 
with  or  without  the  use  of  the  intestinal  pincers  (Fig.  567).  The 
outline  of  the  pyloric  cut  may  be  greater  than  the  caliber  of  the  re- 
maining duodenum  (Fig.  568).  The  caliber  of  the  larger  portion 
must  be  reduced  to  a  suitable  size  to  be  joined  to  its  fellow,  c,  a  to  d, 


HOLLOW   VISCERA   IN   CONTACT   WITH   SEROUS  SURFACES.       359 


Fig.  568. — Outlines  of  incisions. 


e  ;  or  c,  b  may  be  sewed  until  it  shall  conform  in  width  to  d,  e,  to  which 
it  is  sewed,  thus  transferring  the  pyloric  opening  to  the  greater 
curvature  of  the  stomach  ; 
the  Czerny-Lembert  suture 
answers  admirably  for  the 
purpose  ;  or  the  borders  of 
the  openings  may  be  joined 
by  means  of  a  double  row  of 
the  Lembert  form  of  suture. 
The  first  row  should  be  car- 
ried down  to  the  mucous 
membrane,  and  be  inter- 
rupted ;  the  second  row 
should  be  deposited  outside 
of  the  first  one,  and  include 
the  serous  membranes  only. 

This  row  may  be  continuous.  After  all  bleeding  is  checked,  and  the 
peritoneal  cavity  is  thoroughly  cleaned,  the  parts  are  returned  and 
the  abdominal  wound  is  closed  in  the  usual  manner.  The  patient  is 
then  quieted  by  anodynes  and  nourished  by  the  rectum  during  the 
first  three  or  four  days,  until  fluid  food  can  be  given  by  the  mouth. 
The  contraindications  to  the  operation  are  :  Old  or  weak  patients  ; 
evidences  of  malignant  secondary  deposits  ;  existence  of  extensive  ad- 
hesions ;  chronic  incurable  dilatation  of  the  stomach,  etc. 

Results. — Of  the  twenty-three  cases  reported  by  Eydigicr  in  1883, 
five  had  recovered.  Still,  one  of  these  died  four  months  after  the 
operation  from  a  return  of  the  disease.  At  the  present  time  pylorec- 
tomy  has  been  performed  at  least  eighty-two  times,  with  twenty-one 
recoveries  from  the  operation.  Of  thirty-six  cases  for  carcinoma,  seven 
had  recovered  and  two  were  doubtful.  The  prognosis  is  much  better 
in  the  colloid  than  other  forms  of  carcinoma.  In  only  about  five  per 
cent  of  the  cases  were  adhesions  and  enlarged  glands  absent.  Ad- 
hesions to  the  pancreas  and  enlarged  glands  of  the  great  omentum 
were  most  frequent.  Twenty-nine  cases  are  reported  where  it  was 
not  deemed  advisable  to  continue  the  operation,  owing  to  exten- 
sive adhesions,  shock,  etc.  The  time  occupied  in  the  operation  is 
modi  fieri  by  the  complications,  being  from  an  hour  and  a  quarter 
to  five  hours.  The  rate  of  mortality  from  the  operation  is  about  sev- 
enty-five per  cent  as  the  cases  occur.  If  uncomplicated,  it  is  fifty  per 
cent,  heart  failure,  from  shock,  being  the  fatal  element.  The  per- 
age  of  ultimately  successful  cases  is  but  little  above  eight  and  a 
quarter. 

Loreto's  Operation  is  divulsion  of  the  pylorus  by  the  fingers,  or  other 

ilarly  effective  agents.     In  this  the  abdominal  incision  is  made  to 

correspond  to  the  location  of  the  disease  as  in  I  lie  preceding  operation ; 


360  OPERATIVE   SURGERY. 

or,  if  the  condition  will  permit,  it  is  commenced  an  inch  and  a  half  be- 
low the  ensiform  cartilage  and  carried  obliquely  downward  and  out- 
ward for  four  or  five  inches  to  within  an  inch  and  a  half  of  the  ninth 
costal  cartilage  (Fig.  563,  2).  The  opening  is  sometimes  made  through 
the  linea  alba.  The  abdominal  incision  is  made  with  the  same  precau- 
tions as  in  the  preceding  operation.  The  pyloric  extremity  of  the 
stomach  is  drawn  out  and  an  opening  made  into  it  between  and  at 
equal  distances  from  its  two  curvatures,  about  two  and  a  half  inches 
in  length,  beginning  an  inch  and  a  half  from  the  situation  of  the 
pyloric  valve.  The  hemorrhage  is  then  controlled  ;  the  index-finger 
is  introduced  through  the  pyloric  valve  and  carefully  rotated,  with 
pressure  and  counter-pressure.  The  second  finger  is  introduced  beside 
the  former  in  the  same  cautious  manner,  and  so  on  until  the  constricted 
portion  is  well  distended.  The  wound  in  the  stomach  is  then  closed 
by  the  Gely  or  Lembert  suture,  the  parts  are  returned,  and  the  ab- 
dominal wound  is  closed  as  before. 

The  results  of  this  operation  are  much  more  favorable  than  those 
for  excision  of  the  pylorus,  and  it  is  entirely  proper  that  dilatation 
should  be  considered  in  connection  with  it ;  the  incision  through  the 
abdominal  walls  being  made  with  a  view  to  excision,  if  it  be  malignant, 
and  divulsion  if  the  stenosis  be  due  to  non-malignant  causes.  Divul- 
sion  has  been  performed  eight  or  ten  times,  with  a  rate  of  mortality 
varying  from  fifty  to  seventy-five  per  cent. 

OPERATIONS   ON   THE    GALL-BLADDER. 

It  occasionally  happens  that  obstructions  of  the  cystic  duct  and 
distention  of  the  gall-bladder  from  gall-stones  or  other  causes  give  rise 
to  an  abdominal  tumor  of  considerable  size,  which  is  dangerous  on 
account  of  the  liability  to  rupture,  and  is  distressing  from  the  pain 
and  tenderness. 

Cholecystotomy. — This  operation  consists  in  cutting  down  through 
the  abdominal  wall  upon  a  tumor,  caused  by  a  distended  gall-bladder, 
and  evacuating  its  contents.  The  incision  is  made,  as  a  rule,  over 
the  center  of  the  tumor,  parallel  to  the  free  border  of  the  ribs.  At 
first  it  should  be  about  three  inches  in  length,  large  enough  for  ex- 
ploration, after  which,  if  need  be,  it  can  be  enlarged.  The  various 
layers  composing  the  abdominal  wall  are  divided  on  a  director  down 
to  the  peritoneum,  which  should  not  be  opened  until  all  hemorrhage  is 
arrested.  Two  methods  of  procedure  are  now  recommended  :  1.  As- 
certain if  the  serous  covering  of  the  tumor  be  adherent  to  the  parietal 
layer  of  the  peritoneum  ;  if  such  be  the  case,  open  into  the  tumor  and 
evacuate  its  contents.  If  it  be  not  adherent,  and  the  conditions  of  the 
patient  will  permit,  fill  the  wound  with  strips  of  antiseptic  gauze  or 
marine  lint.  After  five  or  six  days  sufficiently  firm  adhesions  will  have 
been  caused  to  permit  the  opening  of  the  gall-bladder,  which  should 


HOLLOW   VISCERA   IN   CONTACT   WITH   SEROUS   SURFACES.        361 

be  done  in  the  same  manner  and  be  treated  in  all  respects  as  the  simi- 
lar step  in  the  second  method  of  procedure.  2.  After  hemorrhage  is 
arrested,  divide  the  peritoneum  cautiously,  catching  its  free  borders 
b}'  forceps,  which  are  then  allowed  to  rest  on  the  surface  of  the  abdo- 
men. If  the  wall  of  the  tumor  be  not  adherent,  introduce  two  fingers 
through  the  opening  into  the  abdominal  cavity,  and  even  the  entire 
hand  if  necessary,  and  examine  the  condition  of  the  contiguous  ab- 
dominal organs,  size  of  the  tumor,  nature  of  its  contents,  etc.,  care 
being  taken  not  to  rupture  it  by  the  manipulation.  If  gall-stones  be 
found  in  the  cystic  or  the  common  ducts,  they  should  be  dislodged  if 
practicable.  If  the  tumor  be  distended  with  fluid,  it  should  now  be 
aspirated,  and  then  held  firmly  in  contact  with  the  external  opening, 
while  an  incision  about  an  inch  in  length  is  made  into  it.  Its  fluid  con- 
tents must  be  carefully  excluded  from  contact  with  the  peritoneal  lin- 
ing, and  also  from  the  raw  surfaces  of  the  incision.  This  can  be  quite 
satisfactorily  accomplished  by  means  of  a  narrow,  trough-like  arrange- 
ment made  of  tin,  gutta-percha,  or  other  suitable  material  to  conduct 
the  fluid  beyond  the  wound.  If  the  cut  surfaces  around  the  point  to  be 
opened  be  smeared  with  carbolic  acid  and  oil,  and  covered  with  small 
pieces  of  antiseptic  gauze,  and  the  borders  of  the  incision  in  the  tumor 
be  quickly  grasped  with  forceps  and  held  upward,  any  danger  of  un- 
wholesome contact  of  the  fluid  will  be  obviated.  The  distended  gall- 
bladder and  its  associated  ducts  are  carefully  examined,  and  all  gall- 
stones are  removed  with  forceps.  The  edges  of  the  opening  in  the 
gall-bladder  are  now  stitched  to  the  abdominal  incision,  a  drainage-tube 
is  introduced,  and  the  whole  is  covered  by  an  antiseptic  dressing.  The 
resulting  fistula  will  soon  close  if  the  common  duct  be  not  obstructed, 
and  the  parts  will  resume  their  normal  functions.  If  the  wall  of  the 
tumor  be  not  adherent  to  the  abdominal  wall,  it  is  recommended  by 
some— after  the  evacuation  of  its  contents — that  the  opening  be  care- 
fully stitched  and  the  sac  returned  ;  also  that  the  sac  be  ligated 
at  its  neck  and  removed.  It  can  not  be  said,  however,  that  these 
procedures  are  as  rational  in  all  respects  as  the  one  more  fully  de- 
scribed. 

Results. — Forty  cases  have  been  reported,  of  which  ten  were  fatal. 
The  second  method  anticipates  the  dangers  of  rupture  and  the  struct- 
ural changes  induced  by  over-distention,  which  are  offset  by  those  of 
opening  into  the  abdominal  cavity  ;  the  latter,  however,  when  done 
under  antiseptic  precautions,  is  rarely  followed  by  an  unfortunate 
result.  These  facts  emphasize  the  wisdom  of  an  early  operative  In- 
terference. 

Cholecystectomy,  or  extirpation  of  the  gall-bladder,  is  employed 
instead  of  cholecystotomy  when,  by  reason  of  the  presence  of  a  trouble- 
some biliary  abdominal  li-t  ula,  malignant  disease,  or  I  amors  of  the  gall- 
bladder, the  latter  is  rendered  useless.     If  the  opening  through  the 


362  OPERATIVE   SURGERY. 

abdominal  walls  be  the  same  as  in  cholecystotomy,  and  the  case  is 
found  to  be  better  adapted  to  cholecystectomy,  the  incision  will  then 
require  to  be  extended  upward  sufficiently  to  command  the  neck  of 
the  sac.  If,  however,  the  latter  operation  be  contemplated  in  the 
beginning,  the  abdominal  incision  can  be  made  in  the  right  hypo- 
chondrium,  parallel  to  the  lower  border  of  the  liver,  and  joined  by  a 
second  incision  running  along  the  outer  border  of  the  right  rectus 
muscle  (Fig.  563,  3).  The  abdominal  cavity  is  then  to  be  opened,  the 
transverse  colon  and  small  intestines  pushed  down  by  a  large  sponge, 
and  the  liver  elevated,  so  as  to  bring  the  hepatic  duodenal  ligament 
into  prominence.  The  gall-bladder  is  easily  separated  from  the  liver, 
the  cystic  duct  exposed  and  ligatured  in  two  places  with  carbolized 
silk,  and  severed  between  them,  the  tumor  removed,  and  the  abdomi- 
nal wound  closed. 

This  operation,  like  the  ones  preceding  it,  should  be  done  with  full 
antiseptic  precautions. 

Results. — Cholecystectomy  has  been  done  six  times,  with  a  death- 
rate  of  fifty  per  cent. 

The  base  of  the  gall-bladder  has  sometimes  been  connected  to  an 
opening  made  in  the  duodenum  to  admit  the  discharge  of  bile  into  the 
intestine,  when  this  had  been  prevented  from  taking  place  by  a  perma- 
nent stoppage  of  the  common  duct.  Nothing  definite  can  be  said,  as 
yet,  of  its  adoption  as  a  practical  measure  in  such  cases. 

Laparotomy,  or  Abdominal  Section. — This  operation  is  employed  to 
overcome  intestinal  obstructions  due  to  various  causes,  such  as  in- 
vagination, adhesions,  etc.,  to  ligature  arteries,  and  for  the  operative 
treatment  of  penetrating  wounds  of  the  abdomen.  Laparotomy  should 
be  divided  into  two  varieties  :  1,  the  explorative  operation  ;  2,  the  op- 
eration in  entirety — i.  e.,  the  addition  of  enterotomy  or  enterectomy, 
etc.,  for  the  relief  of  the  trouble  calling  for  the  abdominal  section. 

Explorative  Laparotomy  consists  in  opening  the  abdominal  cavity, 
usually  in  the  median  line,  sufficiently  to  permit  the  inspection  and 
examination  of  its  contents  for  the  morbid  condition,  and  to  determine 
whether  the  culs-de-sac  of  the  cavity  contain  blood  or  other  extravasa- 
tions. If  nothing  be  found,  or  further  operative  procedure  is  not 
required,  the  abdominal  opening  is  then  closed. 

Results. — The  large  number  of  abdominal  sections  performed,  both 
in  this  country  and  abroad,  with  favorable  results,  serves  to  establish 
the  belief  that  an  explorative  laparatomy,  under  favorable  precau- 
tions, does  not  expose  the  patient  to  any  unusual  dangers. 

If  it  be  performed  for  intestinal  obstruction,  the  opening  can  be 
made  over  the  seat  of  obstruction  ;  but  it  is  better  to  make  it  in  the 
median  line  below  the  umbilicus  (Fig.  563,  4).  It  should  bo  a  free 
incision,  and  of  sufficient  size  to  permit  the  easy  introduction  of  the 
hand,  and  should  be  made  under  strict  antiseptic  precautions.     If  any 


HOLLOW   VISCERA   IN   CONTACT   WITH   SEROUS   SURFACES.        3(33 

difficulty  be  experienced  in  locating  the  seat  of  the  trouble,  or  over- 
coming it,  the  opening  should  be  still  further  enlarged.  Care  must  be 
taken  not  to  tear  or  injure  the  intestine.  It  is  better,  if  the  obstruc- 
tion does  not  yield  readily,  to  raise  the  obstructed  portion  out  of  the 
opening,  and  surround  it,  along  with  such  of  the  intestines  as  may  es- 
cape, with  the  Lister  gauze,  wet  in  a  warm  antiseptic  solution,  or  with 
large  flat  sponges  treated  in  the  same  manner.  As  soon  as  the  obstruc- 
tion is  relieved  and  the  intestines  are  restored  to  their  normal  position, 
the  abdominal  cavity  is  cleaned  by  warm  antiseptic  sponges,  and  the 
external  wound  closed. 

Results. — The  rate  of  mortality  in  all  cases  of  this  character  is 
about  sixty-five  per  cent.  The  prognosis  would  be  much  better  were 
it  not  that  the  diagnosis  is  uncertain,  or  the  operation  objected  to, 
until  the  condition  of  the  patient  almost  precludes  a  successful  issue. 

Enterotomy  consists  in  opening  the  intestine  above  or  at  the  point 
of  an  obstruction,  and,  when  the  opening  is  low  down,  it  may  be  at- 
tached by  its  borders  to  the  abdominal  walls,  thereby  establishing  a 
fecal  fistula. 

This  operation  can  also  be  done  when  the  gut  is  gangrenous  or 
otherwise  unfit  to  be  returned.  At  the  present  time,  in  both  of  these 
conditions,  it  is  thought  to  be  proper  by  some  authorities  to  relieve 
the  obstruction  by  means  of  abdominal  section,  followed  by  enterec- 
tomy  or  enteroraphy,  and  return  the  intestine  into  the  abdominal 
cavity.  The  final  percentage  of  recoveries,  however,  is  much  greater 
if  a  fecal  fistula  is  established  at  first,  which  can  afterward  be  closed 
by  the  usual  method  or  by  enterectomy. 

This  particular  form  of  enterotomy  is  commonly  performed  in 
the  right  iliac  fossa,  since  the  intestines  above  the  obstruction  lie 
principally  in  this  situation.  The  intestines  above  the  obstruction 
are  filled  ;  those  below  are  empty  ;  consequently  the  selection  of  the 
proper  one  to  open  becomes  easy  on  inspection. 

In  "Right  Inguinal  Enterotomy"  (Nelaton),  as  this  operation  is 
sometimes  called,  an  incision  is  made  an  inch  above  Poupart's  liga- 
ment and  parallel  with  it,  beginning  at  the  anterior  superior  spine  of 
the  ilium  and  ending  opposite  the  internal  abdominal  ring  (Fig.  5G3, 
5).  The  layers  of  the  abdominal  walls  are  divided  consecutively  on  a 
director,  down  to  the  peritoneum,  which  is  opened,  after  all  hemor- 
rhage  lias  ceased,  for  one  inch  and  a  half.  The  first  intestinal  loop 
presenting  is  drawn  through,  provided  it  bo  not  an  empty  one  ;  a  long 
thread  is  passed  through  the  muscular  walls  and  looped,  and  the  in- 
testine again  returned  and  kept  from  the  opening  by  a  small-sized 
carbolized  sponge,  to  which  a  Btring  is  attached  ;  this  is  forced  through 
the  opening  and  allowed  to  remain,  while  the  peritoneum  is  drawn 
outward  and  stitched  to  the  integument.  The  Bponge  is  then  re- 
move,!, and   the  intestine  pulled  out  by  the  looped   ligature  which  lias 


364  OPERATIVE   SURGERY. 

remained  upon  the  abdominal  wall.  The  coats  of  the  intestine  are 
carefully  united  to  the  walls  of  the  opening  by  a  deep  row  of  inter- 
rupted carbolized  silk  or  catgut  sutures  passed  in  the  transverse  axis 
of  the  gut,  through  its  serous  and  muscular  coats,  being  entered  two 
or  three  lines  from  the  border  of  the  integumentary  wound,  and,  after 
including  the  gut,  returned  through  the  same  border  of  the  wound 
from  below  upward,  and  tied.  After  the  serous  surfaces  are  accurate- 
ly apposed  by  a  row  of  stitches,  the  intestine  is  raised  to  a  level  with 
the  surface  of  the  abdomen,  and  the  space  between  it  and  the  border 
of  the  abdominal  wound  is  packed  with  absorbent  cotton  or  lint 
saturated  with  carbolic  acid  and  oil  for  the  purpose  of  protecting  their 
surfaces  from  contact  with  any  of  the  intestinal  contents.  The  gut  is 
opened  longitudinally  for  one  inch,  its  edges  being  caught  with  pincers 
as  fast  as  cut.  After  the  intestinal  contents  near  the  opening  are 
evacuated,  a  small  sponge  with  a  string  attacned  should  be  pressed 
into  the  opening  in  the  gut  to  prevent  any  further  escape  while  its 
borders  are  being  carefully  sewed  to  the  integumentary  margin  by  the 
continuous  or  interrupted  suture. 

The  immediate  results  of  this  operation  are  better  than  those  of 
laparotomy  in  entirety,  but  the  patient  is  subjected  thereafter  to  the 
annoyance  of  a  fecal  fistula.  If  the  obstruction  be  due  to  a  foreign 
body  in  the  gut,  and  its  position  be  located,  the  intestine  can  be 
incised,  obstruction  removed,  wound  of  the  intestine  closed  by  the 
Lembert  or  other  suture,  the  gut  returned,  and  the  abdominal  incision 
closed. 

Enterectomy  consists  in  removing  a  segment  of  intestine  and  unit- 
ing the  divided  extremities,  which,  when  combined  with  abdominal 
section,  constitutes  a  laparotomy  in  entirety.  Enterectomy  is  per- 
formed for  penetrating  shot  and  stab  wounds  of  the  intestine,  and  for 
the  removal  of  malignant  growths  and  gangrenous  portions  of  the 
same.  The  antiseptic  precautions  relating  to  the  operator,  to  the 
patient,  and  to  the  surgical  surroundings  should  be  of  the  most  com- 
plete kind,  and,  in  addition  thereto,  the  patient  and  the  abdominal 
viscera  should  be  kept  warm  and  the  latter  moist.  Warmth  and 
moisture  can  be  secured  by  operating  in  a  thoroughly  purified  room, 
charged  with  antiseptic  vapor,  and  having  a  temperature  of  98°  to 
100°  Fahr.  The  warmth  of  the  abdominal  viscera  can  be  quite  well 
maintained  if  they  be  surrounded  by  large,  flat  sponges  or  anti- 
septic gauze  moistened  in  warm  solutions  of  mercuric  bichloride 
(1-10,000),  carbolic  acid  (1-100),  or  Theirsch's  fluid.  If  blood  or 
intestinal  contents  escape  into  the  abdominal  cavity,  the  site  of  the 
injury  causing  it  must  be  sought  for  and  closed.  All  bleeding  points 
should  be  tied  with  fine  catgut,  no  matter  how  insignificant  the 
bleeding  may  seem  at  the  time  ;  for  after  the  parts  are  returned 
into  the  abdominal  cavity,  and  their  normal  relations  and  tempera- 


HOLLOW   VISCERA   IN   CONTACT   WITH   SEROUS   SURFACES.       365 

ture  have  been  restored,  a  trivial  oozing  may  become  a  serious  hem- 
orrhage. All  wounds  of  the  intestine,  at  other  than  its  mesenteric 
attachment,  may  be  closed  by  the  continuous  suture  of  Lembert, 
or  by  the  Gely  suture.  Catgut  or  antiseptic  silk  may  be  used  for 
this  purpose.  A  double  row  of  sutures  may  be  deposited,  provided, 
however,  the  closure  does  not  reduce  the  caliber  of  the  intestine 
more  than  one  third.  If  the  wounds  be  too  large  or  too  closely  as- 
sociated to  admit  of  closure,  or  if  they  be  at  the  mesenteric  border 
of  the  gut,  enterectomy  or  removal  of  the  injured  portion  should 
be  done.  The  contents  of  the  portion  to  be  removed  should  be 
pressed  out  into  the  uninjured  portion  of  intestine,  and  its  return  pre- 
vented by  the  intestinal  pincers  (Fig.  567),  by  the  fingers  of  an  assist- 
ant, or  by  strips  of  iodoformized  gauze  tied  loosely  around  the  gut. 
The  incisions  for  the  removal  of  the  injured  portions  should  be  made 
as  closely  as  possible  to  the  incoming  mesenteric  arteries,  so  that  the 
extremities  of  intestine  will  be  well  nourished.  The  mesentery  may 
be  treated  by  one  of  the  following  methods  :  1.  A  triangular  portion 
of  it  may  be  removed,  its  base  corresponding  to  the  length  of  the  por- 
tion of  intestine  excised,  after  which  the  gap  is  closed  by  bringing  the 
divided  borders  of  the  mesentery  together  and  uniting  them.  2.  It 
may  be  tied  in  small  segments,  about  a  quarter  of  an  inch  from  the 
intestine,  with  catgut,  divided  and  allowed  to  remain  free,  or  may  be 
sewed  to  the  mesenteric  border  of  the  gut  after  it  has  been  repaired. 
3.  The  serous  coat  for  a  quarter  of  an  inch  each  side  of  the  mesen- 
teric attachment  may  be  divided  and  stripped  from  the  subjacent 
tissue,  intestine  excised,  ends  approximated,  and  the  loop  formed  by 
the  serous  slip  closed  by  sutures.  During  the  sewing  the  ends  of  the 
intestine  may  be  held  by  the  fingers  of  an  assistant  or  by  introducing 
a  «mall,  distended  rubber  bag.  Pieces  of  stale  bread  may  be  made  of 
a  size  to  support  the  ends  during  the  sewing.  The  rubber  bag  should 
be  removed  before  the  intestine  is  entirely  closed,  and  care  must  be 
taken  or  it  will  be  sewed  in  position.  The  bread  or  large  macaroni 
tubes  will  escape  from  the  natural  opening.  It  is  difficult  to  manage 
these  extremities  and  at  the  same  time  properly  coapt  the  borders  and 
deposit  the  sutures  so  that  effective  and  permanent  union  will  be 
secured,  since  the  point  above  the  obstruction  will  be  distended  by 
air  and  fecal  accumulation,  while  the  portion  below  will  be  collapsed 
and  appear  smaller  than  normal.  The  mobility  of  the  extremities, 
the  danger  of  the  escape  of  fecal  matter,  together  with  hemorrhage, 
and  the  length  of  time  necessary  to  triumph  over  the  obstacles  already 
enumerated,  bring  about  a  degree  of  exposure  which  adds  more  to 
the  gravity  of  the  operation  than  the  division  and  removal  of  the 
diseased  tissue.  Anything,  therefore,  which  will  expedite  matters  in 
this  cespeci  must  constitute  a  real  advance  in  surgery.  The  instru- 
ment devised  by   Mr.  Treves,  of  London  (Fig.  569),   ia  certainly  in- 


366 


OPERATIVE   SURGERY. 


genious,  but  does  not  seem  to  be  sufficiently  simple  to  become  of 
practical  utility.  It  can  not  be  better  described  than  in  Mr.  Treves' 
own  language  :   "  The  apparatus  consists  in  the  first  place   of  two 

clamps,  b  b,  to  secure  the  gut,  e  e, 
above  and  below  the  point  of  resec- 
tion. Each  clamp  is  made  of  two 
separate  and  light  metal  bars,  pro- 
vided with  an  India-rubber  pad  on 
the  surfaces  that  are  in  contact  with 
the  gut.  The  clamp  is  two  inches 
and  a  half  in  length,  and,  one  part 
being  placed  beneath  the  gut  and 
the  other  upon  it,  the  two  are  then 
approximated  by  screws  placed 
at  each  end.  By  these  means 
the  gut  can  be  evenly  and  ac- 
curately compressed  with  as 
much  or  as  little  force  as  may 
be  thought  fit.  I  first  apply  a 
clamp  to  the  gut  one  inch  and  a 
half  below  the  proposed  resection- 
line,  and,  having  emptied  the  part 
to  be  excised  by  squeezing  its  con- 
tents upward,  I  apply  the  second 
clam}?  at  a  similar  distance  beyond 
the  second  resection-line,  which  will, 
in  most  cases,  insure  an  empty  con- 
dition of  the  part  to  be  removed. 
A  triangular  piece  of  mesentery 
should  then  be  excised,  the  base  of 
the  triangle  exactly  corresponding 
to  the  amount  of  gut  to  be  re- 
moved ;  secure  the  divided  vessels 
and  excise  the  diseased  gut.  The 
clamps  are  now  united  with  each 
other  by  means  of  the  long,  narrow 
reel-rods,  A  A,  which  are  secured  to 
each  clamp  by  a  small  screw.  By 
means  of  these  bars  the  two  clamps 
can  be  evenly  approximated,  and 
the  divided  ends  of  the  gut  brought 
into  accurate  contact.  If  the  screws 
be  now  tightened,  the  bowel  extrem- 
ities are  held  in  a  rigid  frame,  and  can  be  turned  or  moved  in  any 
direction  without  disturbing  the  contact  of  the  divided  ends.     The 


Fig.  569. — Treves'  apparatus  for  en- 
terectomy. 


HOLLOW   VISCERA   IN   CONTACT   WITH  SEROUS   SURFACES.       JJ67 


ends  to  be  united  will  be  easily  commanded  if  a  very  thin  India-rubber 
bag,  G,  about  three  inches  in  length,  of  sausage-shape,  that  can  be 
distended  by  air  to  a  large  size,  be  inserted  about  the  middle  of  its 
long  axis.  Having  blown  out  this  bag  till  it  was  about  the  size  of  the 
divided  bowel,  I  inserted  one  end  into  the  lower  piece  of  the  intestine 
and  the  other  end  into  the  upper  piece.  The  supply-tube,  d,  will 
thus  occupy  the  suture-line.  After  the  bag  is  suitably  distended  the 
sutures  are  applied  all  round  the  gut,  and  almost  up  to  the  interrup- 
tion in  the  suture-line  occupied  by  the  tube  that  fills  the  bag.  The 
last  sutures  are  then  applied,  but  not  tied,  the  bag  exhausted  of  air 
and  withdrawn  from  the  bowel  through  the  interruption  in  the  suture- 
line."  Two  rowrs  of  sutures  should  be  used — the  first  an  interrupted 
Lcmbert  of  iron-dyed  silk,  extending  to  the  mucous  membrane ; 
second,  the  continuous  Lembert,  including  the  serous  surfaces  only. 
The  Czerny- Lembert  is  entirely  suitable  for  this  purpose.  Great  care 
is  requisite  to  properly  close  the  mesenteric  border  of  the  intestine. 
A  small  artery  is  found  here  that  often  bleeds  persistently.  The  en- 
tire intestinal  tract  should  be  carefully  examined  for  other  injuries, 
even  though  it  be  necessary  to  remove  the  intestines  from  the  cavity 
to  do  it.  Severe  intestinal  contusions  should  be  treated  like  pene- 
trating wounds  of  the  intestine.  The  "toilet"  of  the  abdominal 
cavity  must  be  patiently  and  thoroughly  performed  by  soft,  moist, 
antiseptic  sponges.  It  is  not  enough  to  wipe  off  the  intestines  only, 
but  all  the  culs-de-sac  must  be  examined,  and  all  blood  and  other  ex- 
travasations, together  with  antiseptic  fluids  found  therein,  should  be 
sponged  out  and  drainage  provided  if  deleterious  discharges  appear 
likely  to  be  produced.    The  abdominal  wound  is  dressed  antiseptically. 

.Results. — The  general  result 
shows  a  death-rate  of  about  fifty 
per  cent.  This  is  very  satisfacto- 
ry, when  it  is  considered  that 
over  ninety  per  cent  of  penetrat- 
ing shot-wounds  of  the  abdomen 
die  when  treated  expectantly. 
When  this  operation  is  done  for 
causes  that  do  not  involve  ex- 
travasation into  the  abdominal 
cavity,  the  death-rate  is  much 
diminished.  It  is  not  advisable 
to  excise  the  intestine  for  malig- 
nant disease  if  the  mesenteric 
glands  be  much  involved,  since 
an  artificial  anus  can  then  be 
made  with  better  prospects  of 
prolonging  life.  Fio.  670.— Guide  to  colon. 


3gg  OPERATIVE   SURGERY, 

Left  Lumbar  Colotomy  (Amussat).— In  this  operation  the  descend- 
ing colon  is  opened  between  the  crest  of  the  ilium  and  the  last  rib. 

Linear  Guide  to  the  Operation  (Fig.  570).— Draw  a  line  which  shall 
connect  the  anterior  and  posterior  superior  spinous  processes  of  the 
ilium ;  draw  a  second  line  perpendicular  to  this,  one  inch  posterior 
to  its  center.  This  line  marks  the  course  of  the  colon.  Draw  a  third 
line  four  inches  in  length  obliquely  downward  and  outward,  midway 
between  the  lower  border  of  the  last  rib  and  the  crest  of  the  ilium, 
its  center  corresponding  to  the  perpendicular  one,  parallel  with  the 
lower  border  of  the  last  rib.  The  third  line  marks  the  course  of  the 
incision,  half  of  which  is  behind  the  perpendicular  line. 

Muscular  Guides. — The  outer  border  of  the  erector  spinse,  also 
the  outer  border  and  anterior  surface  of  the  quadratus  lumborum. 

Contiguous  Anatomy. — The  colon  at  this  situation  is  covered  by 
peritoneum  at  its  anterior  surface  and  sides  ;  its  posterior  internal 
surface  is  not  covered  by  this  membrane.  If  the  gut  be  collapsed,  it 
retreats  toward  the  median  line,  behind  the  quadratus  lumborum,  and 
is  followed  by  its  peritoneal  covering.  The  collapsed  condition  of  the 
gut,  therefore,  exposes  the  peritoneum  to  greater  danger  of  being  in- 
jured. When  distended,  it  presses  its  peritoneum  outward,  and  can 
be  readily  seen  projecting  beyond  the  outer  border  of  the  quadratus 
lumborum.  The  surfaces  not  covered  by  peritoneum  are  surrounded 
by  areolar  tissue,  which  separates  the  intestine  from  the  left  crus  of 
the  diaphragm,  the  left  kidney,  and  anterior  surface  of  the  quadratus 
lumborum  ;  and  externally  it  is  in  contact  with  the  small  intestines. 
The  left  kidney  is  situated  posteriorly  to  it,  and  its  lower  extremity 
can  be  easily  felt  at  the  upper  border  of  the  wound.  The  vessels 
lying  in  the  course  of  the  incision  are  the  abdominal  branches  of  the 
lumbar  vessels.  The  ilio-hypogastric  and  ilio-inguinal  nerves  likewise 
cross  in  front  of  the  quadratus  lumborum  at  this  situation. 

The  colon  is  recognized  by  its  greenish  color  and  its  longitudinal 
bands,  which  are  three  in  number — one  anteriorly,  which  is  covered 
by  peritoneum,  a  second  corresponding  to  its  attachment,  the  third  or 
lateral  at  its  inner  side.  It  is  not  quiet  during  respiration,  although 
it  does  not  move  upward  and  downward  as  the  small  intestines  are 
sure  to  do.  It  can  not  be  raised,  while  the  small  intestines  can. 
Finally,  if  it  be  filled  with  air  after  the  fascia  lumborum  is  divided, 
and  the  fat  be  pushed  aside,  it  will  become  distended  quickly  and 
assume  a  proportionately  greater  size  than  the  small  intestines. 

Fallacies. — The  colon  may  be  mistaken  for  a  loop  of  small  intes- 
tine, also  for  the  kidney,  especially  in  the  young  subject.  From  the 
former  it  is  readily  distinguished  by  the  differences  already  given ; 
from  the  latter,  by  the  density  of  the  structure  of  the  kidney,  its 
rounded  extremities,  reniform  shape,  lobulated  appearance,  and  the 
upward  and  downward  movements  of  the  kidney  with  the  respiratory 


HOLLOW   VISCERA   IN   CONTACT   WITH   SEROUS   SURFACES.        369 

acts.  If  the  preceding  be  not  satisfactory,  the  introduction  of  a  hypo- 
dermic needle  will  demonstrate  not  only  the  density  of  the  kidney,  but 
the  absence  of  fecal  matter  and  offensive  gases. 

If  the  conditions  will  permit,  the  bowel  should  be  thoroughly 
washed  out  before  the  operation  is  begun  ;  after  which  the  patient  is 
etherized  and  placed  on  the  right  side,  with  a  hard  pillow  under  the 
loin,  so  that  the  left  side  may  be  made  more  prominent. 

Operation. — An  incision  is  made  in  the  course  of  the  line  already 
marked  out,  and  carried  through  the  integument,  fascia,  and  thick 
layer  of  fat  usually  found  at  this  situation,  down  to  and  through  the 
latissimus  dorsi  muscle  and  the  posterior  fibers  of  the  external  oblique, 
the  internal  oblique,  and  transversal  is,  which  are  divided  upon  a  di- 
rector, bringing  into  view  (Fig.  571)  the  outer  portion  of  the  quad- 


/,  A 


m  --  v 


Via.  "'71— Surreal  relations  of  descending  colon,  a.  spine  of  fourth  lumbar  vertebra. 
b.  Cartilage  between  third  and  fourth  vertebrae,  c.  Umbilicus,  d.  Quadratus  lumbo- 
rurn  m.  ft  Psoas  magnua  m.  /.  External  oblique  m.  g.  Rectus  muscle,  h.  Descend- 
ing' colon,  covered  anteriorly  and  externally  by  peritoneum,  i.  Transverse  colon,  j. 
Aorta.  /•.  Inf.  vena  cava.  /.  Ureter,  m.  Adipose  tissue  covered  by  the  transversalis 
fascia,     n.  Internal  oblique  muscle,     o.  Transversalis  m.    p.  Reflection  of  peritoneum. 

ratua  lumborum  inclosed  within  its  compartment  of  the  lumbar  apo- 
neurosis, which  extend-  outward  to  become  continuous  with  the  trans- 
rersalis  muscle.  The  aponeurosis  is  carefully  divided  upon  a  director, 
and  the  fascia  transversalis  that  lies  beneath  it  is  divided  in  n  similar 

manner,  thus  bringing  into  view  the  fatty  areolar  tissue  that  separates 
the  gnt  from  the  quadratus  lumborum  and   the  left  cms  of  the  dia- 

24 


370 


OPERATIVE   SURGERY. 


phragm.  The  fat  is  pushed  aside  by  the  finger  and  handle  of  the 
scalpel,  and  the  bowel  distended  with  air,  when  its  situation  will 
become  positive.  By  the  means  already  given,  confirm  its  identity 
before  proceeding  further.  As  soon  as  the  gut  is  distended  it  will 
appear  at  the  opening,  and  perhaps  even  rise  above  its  level ;  roll  it 
outward  with  the  finger  from  beneath  the  quadratus,  cutting  the  outer 
border  of  the  muscle,  if  necessary,  so  as  to  reveal  its  inner  aspect, 
which  is  known  by  the  longitudinal  band  ;  seize  it  with  a  tenaculum 
or  forceps,  and  hold  it  upward  while  a  stout,  curved  needle,  armed 
with  a  well-carbolized  silk  ligature,  is  passed  deeply  through  the  skin 
and  deeper  tissues  at  one  side  of  the  perpendicular  incision,  about 
four  lines  from  the  border,  into  and  transversely  through  the  intestine, 
to  emerge  on  the  other  side  of  the  opening  at  a  similar  distance  from 


Fig.  5"72. — Surgical  relations  of  ascending  colon.  1.  Spinous  process  of  fourth  lumbar 
vertebra.  2.  Cartilage  between  third  and  fourth  vertebras.  3.  Erector  spina;  m.  4 
Inferior  vena  cava.  5.  Psoas  magnus  m.  6.  Fascia  lumborum.  V.  Subcutaneous  fat 
and  latissimus  dorsi  m.  8.  Quadratus  lumborum  m.  9.  Adipose  tissue  covered  bv  the 
transversahs  fascia.  10.  Cavity  and  wall  of  the  ascending  colon.  11.  Internal  oblique 
m  12  External  oblique  m.  13.  Limits  of  peritoneal  reflection.  14.  Transversalis  m. 
15.  Ureter.     16.  Great  omentum.     17.  Rectus  muscle. 


HOLLOW   VISCERA   IN   CONTACT  WITH   SEROUS   SURFACES. 


n 


the  border  of  the  wound  ;  this  suture  is  drawn  through,  and  each  end 
given  to  an  assistant.  The  needle  is  then  passed  in  a  similar  manner 
at  the  opposite  extremity  of  the  incision,  and  its  ends  are  also  given 
to  an  assistant  (Fig.  573).  All  the  space  between  the  walls  of  the  gut 
and  borders  of  the  wound  is  then  packed  with  lint  saturated  with 
carbolic  acid  and  oil.  The  gut  is  opened  by  a  longitudinal  or  oblique 
incision,  about  an  inch  and  a  half  long  (Fig.  574).     The  liability  to  a 


Fig.  5T3. — Sutures  passed  through  colon. 


Fig.  574. — Hooking  up  sutures. 


subsequent  protrusion  of  the  mucous  membrane  and  of  injury 
peritoneum  at  the  time  is  less  with  a  longitudinal  than  with  a 
verse  incision.  After  the  contents 
of  the  bowel  are  evacuated,  a 
sponge,  with  a  string  attached, 
should  be  pressed  into  the  open- 
ing to  retain  any  remaining  dis- 
charge until  the  edges  of  the  gut 
have  been  stitched  to  the  borders 
of  the  wound.  The  finger  or 
hook  should  now  be  inserted  into 
the  bowel,  and  the  loops  of  the 
ligature  just  passed  be  caught, 
drawn  out  (Fig.  574),  and  divided 
at  the  middle,  when  each  one  will 
become  t  wo  distinct  sutures  which, 
after  the  oiled  lint  has  been  re- 
moved and  the  wound  cleansed, 
can  be  tied  (Fig.  575).     The  re- 


to  the 
trans- 


372  OPERATIVE   SURGERY. 

maining  portion  of  the  gut-wound  is  then  stitched,  sprinkled  with 
iodoform  (Fig.  576),  and  a  carbolized  pad  is  bound  over  the  open- 
ing.    This  pad,  together  with  the  sponge,   must 
soon  be  removed  to  allow  the  escape  of  fecal  mat- 
ter.    If  malignant  disease  of  the  rectum  be  the 
cause  for  the  operation,  it  is  recommended  to  bring 
the  intestine  through  the  opening  as  far  as  possi- 
ble, divide  it,  turn  in  the  borders  of  the  upper  ex- 
tremity of  the  lower  portion,  sew  them  together, 
and  drop  it  into  the  abdominal  cavity.     This  plan 
will  prevent  any  fecal  matter  from  passing  down 
the  rectum  and  irritating  the  malignant  growth. 
Fig.  oY6.— Wound      The  upper  opening  is  then  carefully  sewed  to  the 
borders  of  the  abdominal  wound.     Great  caution 
is  necessary  in  taking  these  steps,  or  the  peritoneal  covering  of  the 
colon  will  be  torn  through.     If  this  accident  should  happen,  close  the 
peritoneal  opening  with  catgut  sutures.     Inflammatory  products,  and 
even  fecal  matter,  may  collect  below  if  great  care  be  not  observed. 

Results. — The  rate  of  mortality  from  this  operation  is  variously 
estimated,  being  from  twenty  to  thirty-eight  per  cent.  Eecently  Dr. 
Bott  reported  two  hundred  and  forty-four  cases,  with  a  death-rate  of 
a  little  more  than  thirty-one  and  one  half  per  cent. 

Right  Lumbar  Colotomy. — In  this  operation  the  incision  is  made 
at  the  right  side.  Its  formation,  however,  is  in  all  respects  governed 
by  the  same  rules  as  the  preceding.  The  caput  coli  is  the  portion  to 
be  opened,  and,  owing  to  its  size,  can  be  more  readily  distinguished 
than  the  colon  on  the  left  side  of  the  body  (Fig.  572). 

The  results  are  much  less  favorable,  owing  partly  to  the  loss  of  the 
function  of  the  colon,  and  also  to  the  more  objectionable  location  of 
the  disease  compelling  the  operation  in  this  situation. 

Left  Inguinal  Colotomy  (Littre). — This  operation  consists  in  open- 
ing into  the  sigmoid  flexure  of  the  colon  by  an  incision  into  the  left 
iliac  fossa  through  the  abdominal  walls,  including  the  peritoneum. 

Linear  Guide  to  the  Operation. — Draw  a  line  two  inches  in  length 
over  the  left  iliac  fossa,  commencing  about  an  inch  internally  to  the 
anterior  superior  spine  of  the  ilium,  and  extending  downward  parallel 
with  Poupart's  ligament  (Fig.  563,  6). 

Operation. — The  patient  is  placed  upon  his  back,  and  an  incision 
made  to  correspond  to  the  line  given  above.  All  hemorrhage  is  stopped 
before  the  peritoneum  is  opened.  As  soon  as  the  peritoneum  is  cut, 
insert  a  small  antiseptic  sponge  connected  with  a  string,  which  will 
prevent  the  escape  of  the  intestines ;  stitch  the  peritoneum  to  the 
integumentary  border  ;  withdraw  the  sponge,  and  draw  out  the  intes- 
tine which  is  located  directly  under  the  opening,  and  which  can  be 
recognized  by  the  peculiarly  shaped  fatty  fringe  attached  to  it.     This 


HOLLOW   VISCERA   IN   CONTACT   WITH   SEROUS   SURFACES.        373 

is  then  stitched  to  the  external  wound  in  the  same  manner  as  in  the 
lumbar  region.  In  all  respects  the  treatment  is  the  same  as  for  colot- 
omy  in  other  situations. 

Results. — Left  inguinal  colotomy  is  not  as  safe  an  operation  as  that 
in  the  left  lumbar  region,  since  the  peritoneum  is  directly  involved. 

The  rate  of  mortality  is  from  ten  to  twenty  per  cent  greater. 

Abscess  in  the  Right  Iliac  Fossa. — This  abscess  may  be  super- 
ficially or  deeply  seated.  If  it  be  of  the  former  character,  it  can  be 
opened  readily. 

Operation. — If  the  development  of  a  deep-seated  abcess  be  sus- 
pected, aspiration  should  be  frequently  performed  to  detect  the  earliest 
existence  of  pus.  If  pus  be  found,  make  an  incision  four  or  six  inches 
in  length,  commencing  an  inch  internal  to  and  above  the  anterior 
superior  spinous  process  of  the  ilium,  and  extending  downward  parallel 
with  Poupart's  ligament ;  divide  cautiously  the  various  layers  of  the 
abdominal  wall  on  a  director,  and,  when  the  abscess  wall  is  reached, 
insert  an  aspirating-needle  again  as  a  precautionary  measure ;  open 
the  cavity  freely  in  the  course  taken  by  the  needle  ;  wash  it  thorough- 
ly, insert  a  drainage-tube,  and  allow  it  to  heal  from  the  bottom. 

If  pus  be  not  present,  the  incision  may  be  made,  if  expedient,  and 
the  wound  allowed  to  remain  open,  when,  if  pus  form,  its  discharge 
can  be  readily  effected. 

Results. — This  operation  is  to  be  earnestly  commended  to  the  at- 
tention of  all  practitioners  of  medicine  and  surgery.  The  association 
of  typhlitis  with  abscess  located  in  this  situation,  and  the  great  danger 
to  the  patient  from  a  rupture  into  the  abdominal  cavity,  emphasize 
the  necessity  of  an  early  diagnosis  and  a  thorough  treatment.  The 
prognosis  is  flattering  when  active  measures  are  early  and  promptly 
taken. 

Artificial  Anns,  or  Fecal  Fistula. — When  the  distal  extremity  of 
the  bowel  is  pervious  and  the  fistula  has  served 
its  purpose,  it  should  be  closed.     If  the  sep- 


tum   between   the   openings   be   shallow  and 
yielding,  it  can  be  forced  back  by  means  of  a  „x  >' 

sponge  pressed  against  it  and  confined  in  po-  s  ^  y  f  y«% 
sition  ;  wooden  plug3  and  lint  are  employed 
in  a  similar  manner  ;  failing  in  this,  the  sep- 
tum should  be  grasped  by  a  clamp  or  entero- 
tome  (Fig.  577),  passed  into  the  opening  on 
either  Bide  of  it,  and  the  blades  firmly  screwed 
together.  In  a  few  days  the  constricted  por- 
li.n  sloughs,  and  the  instrument  is  released. 
The  external  opening  usually  closes  spontane- 
ously ;  if  not.  a  plastic  operation  may  become  Yl(.  r>11_Kl)tvvoUmc  ap. 
necessary.     If  these  methods  fail,  the  affection  plied. 


374  OPERATIVE   SURGERY. 

may  be  cured  by  enterectomy,  as  was  practiced  by  Kinloch,  of  South 
Carolina,  in  1863. 

OPEBATIONS   ON"   THE   KIDNEYS. 

The  surgery  of  the  kidney  has  made  rapid  strides  within  the  last 
few  years.  The  accepted  operations  on  this  organ  are  nephrotomy, 
nephrectomy,  nephro-lithotomy,  and  nephroraphy  or  fixation  of  a 
movable  kidney. 

Nephrotomy. — Nephrotomy  consists  in  opening  into  the  kidney 
through  an  incision  in  the  lumbar  region.  The  operation  should  be 
preceded  by  the  introduction  of  an  aspirating  needle,  both  to  locate 
and  define  the  nature  of  the  tumor. 

Operation. — The  patient  is  placed  in  the  same  position  as  in  lum- 
bar colotomy.  The  incision  is  made  in  the  same  direction  ;  and  in 
other  respects  its  location  is  similar,  although  it  is  often  made  nearer 
to  the  last  rib  than  in  colotomy.  A  vertical  incision,  just  outside  the 
quadratus  lumborum,  extending  from  a  point  immediately  below  the 
last  rib  four  or  five  inches  downward,  is  preferred  by  some.  The 
same  precautions  preparatory  to  and  attending  the  operation  are  re- 
quired that  characterize  colotomy,  and  the  tissues  resting  upon  the 
tumor  are  divided  in  the  same  manner.  When  the  sac  is  reached  it 
should  be  aspirated  to  confirm  the  diagnosis.  An  opening  is  then 
made  into  it,  the  contents  evacuated,  and  the  cavity  washed  out  with 
a  solution  of  the  bichloride  of  mercury,  1  part  to  2,000  of  water. 
Carbolic  solutions  should  be  avoided,  since  carbolic-acid  poisoning 
seems  more  likely  to  occur  from  its  use  in  this  situation  than  else- 
where. 

Eemove  all  calculi  that  may  be  present,  and  unite  the  edges  of  the 
kidney  to  the  wound,  and  allow  it  to  heal  by  granulation  ;  or  a  drain- 
age-tube is  inserted  and  the  external  opening  is  closed  by  deep  sutures, 
and  dressed  antiseptically. 

If  the  kidney  structure  be  destroyed,  or  be  the  seat  of  malignant 
disease,  it  is  then  wise  to  remove  the  entire  organ. 

Results. — Nephrotomy  has  been  practiced,  for  various  causes,  nearly 
one  hundred  and  twenty-five  times,  with  an  average  mortality  of  about 
twenty  per  cent.  The  death-rate  after  operations  for  calculous  pye- 
litis was  about  forty-three  per  cent,  but  for  other  causes  in  no  case 
did  it  reach  eighteen  per  cent. 

Nephrectomy. — Nephrectomy  consists  in  removing  the  kidney  in 
part,  or  entirely,  from  the  body.  The  removal  is  indicated  in  cases 
of  a  wounded  or  painful  floating  kidney,  cystic  kidney,  hydronephro- 
sis, pyelitis,  with  or  without  calculi,  neoplasm,  and  urinary  fistula 
from  a  communication  with  the  ureter.  Before  the  operation  is  per- 
formed, it  should  be  ascertained,  if  possible,  whether  the  other  kidney 
is  present,  and  in  a  healthy  condition. 


HOLLOW   VISCERA   IX   CONTACT   WITH   SEROUS  SURFACES.       375 

The  primary  incision  may  be  made  in  the  loin  or  through  the  ab- 
dominal walls ;  which  is  the  better  one  is  a  matter  as  yet  unsettled. 
The  character  of  the  case  will  have  much  to  do  in  determining  this 
point.  If  the  tumor  be  movable,  malignant,  of  large  size  and  ad- 
herent, or  if  it  be  suspected  that  the  disease  be  bilateral,  the  abdomi- 
nal incision  is  preferred,  since  it  admits  of  the  examination  of  the 
other  kidney. 

The  rate  of  mortality,  however,  favors  the  lumbar  incision. 

Lumbar  Nephrectomy  is  to  be  done  with  every  possible  antiseptic 
precaution.  The  primary  incision  is  made  usually  in  the  same  situa- 
tion and  direction  as  in  nephrotomy,  although  the  vertical  one,  in  large 
tumors,  is  highly  commended.  If  the  space  will  permit,  the  tumor  is 
isolated,  and  its  pedicle  tied  en  masse,  or,  what  is  better,  the  vessels 
are  secured  separately.  The  ureter  must  always  be  tied,  and  the  lower 
extremity  brought  through  the  external  opening.  It  often  happens 
that  the  size  of  the  tumor  and  its  adhesions  to  surrounding  tissues  re- 
quire the  opening  to  be  enlarged.  This  can  be  done  by  extending  it 
toward  the  spine  as  well  as  in  the  opposite  direction.  If  the  opening, 
when  taken  in  conjunction  with  the  additional  space  to  be  gained  by 
pushing  upward  the  last  rib,  be  inadequate,  the  rib  can  be  resected 
subperiosteally  for  three  or  four  inches,  and  this  will  be  found  to 
afford  quite  sufficient  room. 

After  the  removal  of  the  tumor,  the  wound  should  be  thoroughly 
disinfected  with  a  solution  of  carbolic  acid  or  other  suitable  substance  ; 
ureter  secured  externally,  and  the  opening  closed' by  deep  sutures,  and 
dressed  antiseptically. 

Abdominal  Nephrectomy. — In  abdominal  nephrectomy  the  opening 
into  the  abdominal  cavity  can  be  made  in  three  situations  :  1,  the 
most  frequent  situation  is  through  the  linea  alba  ;  2,  at  the  outer  side 
of  the  rectus  (linea  semilunaris)  ;  3,  in  the  inguinal  region.  The  first 
two  require  that  the  peritoneum  be  divided  ;  the  last  admits  of  a  sub- 
peritoneal removal,  but  can  scarcely  be  employed  except  in  well-marked 
cases  of  movable  kidney.  In  either  case  the  abdominal  opening  is  made 
in  the  usual  cautious  manner,  about  six  or  eight  inches  in  length,  and 
larger  if  the  size  of  the  tumor  demand  it.  The  hand  is  introduced, 
tumor  located  and  outlined,  and  the  condition  of  the  other  kidney 
noted.  The  diseased  organ  is  then  enucleated  and  raised  through  the 
opening,  its  vessels  and  the  ureter  are  tied  separately  with  strong  carbo- 
lized  ligatures,  and  are  cut  short,  and  returned.  The  opening  remain- 
ing in  the  peritoneum  after  the  removal  of  the  kidney  can  be  closed 
after  all  hemorrhage  lias  ceased  by  uniting  its  divided  borders  with  lino 
catgut.  The  abdominal  cavity  is  then  cleansed  of  all  foreign  matter, 
and  its  walls  united  and  dressed  antiseptically.  If  the  ureter  is  to 
be  returned  into  the  cavity  of  the  abdomen,  its  extremity  should  be 
thoroughly  asepticized  with  the  carbolic  acid,  or  the  bichloride  of 


376  OPERATIVE   SURGERY. 

mercury  solution.  It  is  considered  better,  however,  to  attach  it  to 
the  abdominal  opening.  It  is  recommended  to  tie  the  vessels  of  the 
pedicle  before  commencing  the  enucleation,  thus  lessening  the  danger 
of  hemorrhage.  The  advantages  of  an  opening  outside  of  the  rectus 
are  said  to  be,  less  hemorrhage  from  the  abdominal  walls  than  when 
the  opening  is  made  through  the  linea  alba ;  also,  it  brings  the  sur- 
geon more  directly  on  the  tumor,  its  pedicle,  and  the  ureter.  If  the 
space  from  which  the  tumor  has  been  removed  be  a  large  one  and 
show  a  strong  tendency  to  bloody  oozing  from  the  surface,  the  perfo- 
rated glass  drainage-tube  should  be  introduced,  carried  directly  to  the 
bottom,  and  allowed  to  protrude  through  the  abdominal  incision. 
The  fluid  which  accumulates  in  the  tube  can  be  removed  by  carbolized 
sponges  under  the  antiseptic  spray.  Drainage  may  also  be  provided 
by  passing  a  small  drainage-tube  through  the  abdominal  wall  in  the 
lumbar  region,  communicating  with  the  former  site  of  the  diseased 
organ  ;  then  the  posterior  peritoneal  incision  should  be  closed. 

It  is  impossible  to  lay  down  more  than  the  general  means  of  pro- 
cedure in  this  operation,  since  the  conditions  surrounding  individual 
cases  often  call  for  the  employment  of  other  than  stereotyped  rules. 

Results. — Of  two  hundred  and  thirty-three  nephrectomies  collated 
by  Prof.  S.  W.  Gross,  about  forty-five  per  cent  died.  The  mortality 
from  the  lumbar  incision  was  forty  per  cent,  that  from  the  abdominal 
incision  about  fourteen  per  cent  greater.  Shock  was  the  cause  of 
death  in  forty  per  cent  of  the  entire  number  operated  upon. 

Nephrolithotomy,  or  renal  lithotomy,  is  the  exploration  of  the  pel- 
vis of  the  kidney  with  a  long  needle,  to  ascertain  the  presence  of  cal- 
culi within  it.  If  calculi  be  present,  they  are  removed  with  forceps, 
through  an  incision  made  into  the  kidney. 

Operation. — The  external  opening  is  made  similar  to  that  for  lum- 
bar nephrotomy  ;  the  kidney  is  exposed,  calculus  detected,  and  an  in- 
cision is  made  through  the  cortex  into  the  pelvis  in  the  long  axis  of 
the  kidney  of  sufficient  size  to  remove  it  with  suitable  forceps.  The 
hemorrhage  resulting  from  the  division  of  the  kidney  structure  is 
quite  severe  at  first,  but  is  quickly  controlled  by  pressure.  The 
wound  in  the  kidney  usually  heals  readily ;  nevertheless,  urine  will 
sometimes  escape  through  it  for  ten  or  twelve  days.  With  a  view  to 
cause  union  of  its  structure,  the  lips  of  the  kidney-wound  have  been 
united  by  fine  catgut  sutures  with  favorable  results.  The  external 
wound  is  suitably  drained,  closed,  dressed  antiseptically,  and  the  pa- 
tient given  demulcent  drinks. 

Results. — All  of  the  reported  cases  (six)  of  this  operation  have  ter- 
minated favorably. 

Nephrorraphy  {Fixation  of  a  Floating  Kidney).— To  accomplish 
this  purpose  in  cases  where  all  ordinary  means  have  failed,  an  incis- 
ion is  made  from  a  little  below  the  lower  rib  to  the  crest  of  the  ilium, 


HOLLOW  VISCERA   IN   CONTACT   WITH   SEROUS  SURFACES.       377 

along  the  outer  border  of  the  erector  spinae,  and  down  to  the  quad- 
ratic lumborum.  The  same  tissues  are  encountered  in  this  as  in  the 
vertical  incision  of  nephrotomy.  There  is  a  greater  danger  of  hemor- 
rhage, however,  than  from  the  oblique  incision,  as  the  vertical  incis- 
ion is  made  at  nearly  right  angles  to  the  lumbar  vessels.  As  soon 
as  the  fascia  lumborum  is  divided,  the  kidney  should  be  pushed  into 
the  wound,  the  fascia  transversalis  slit  up,  the  fatty  capsule  surround- 
ing the  kidney  opened  longitudinally,  and  its  borders  stitched  to  the 
deep  structures  of  the  wound  with  eight  or  ten  catgut  or  carbolized 
silk  sutures.  The  wound  is  then  stuffed  with  carbolized  gauze  and 
allowed  to  heal  from  the  bottom  ;  the  patient  remaining  in  the  dorsal 
position  until  the  healing  is  well  completed  ;  after  which,  any  of  the 
various  forms  of  pads  or  other  retentive  apparatus  may  be  applied  to 
retaiu  it  until  the  adhesions  are  thoroughly  established. 

Results. — Nephrorraphy  has  been  performed  eighteen  times,  with 
one  death.  In  about  forty-four  per  cent  of  the  cases  but  little  or  no 
relief  was  gained.  Forty-one  per  cent  die  from  nephrectomy  for  this 
condition. 

The  subsequent  giving  way  of  the  fixation  point  under  the  influ- 
ence of  movement,  suggests  the  practicability  of  continuously  wearing 
some  form  of  retentive  apparatus. 

Splenectomy,  which  consists  in  the  removal  of  the  spleen,  has  been 
performed  between  thirty-five  and  forty  times.  It  has  not  proved  suc- 
cessful, however,  in  any  instance  when  practiced  for  leucocythemia. 
When  employed  for  displacement  or  simple  hypertrophy,  the  results 
are  flattering,  being  in  excess  of  fifty  per  cent. 

Operation. — An  incision  about  eight  inches  in  length  is  made  at 
the  outside  of  the  rectus  or  in  the  median  line,  its  center  corresponding 
to  the  umbilicus  ;  the  peritoneal  cavity  is  opened  in  the  usual  manner, 
the  omentum  and  intestines  displaced,  and  the  tumor  carefully  raised 
through  the  opening  ;  after  which  the  vessels  at  the  hilum,  and  those 
of  the  gastro-splenic  omentum,  are  clamped  and  tied.  This  omentum 
should  be  divided  into  several  sections  by  transfixion,  and  each  sec- 
tion should  be  tied  by  two  ligatures  and  divided  between  them.  All 
hemorrhage  is  stopped,  and  the  abdominal  wound  closed  either  with 
or  without  a  drainage-tube,  depending  on  the  amount  of  prospective 
oozing. 

Tin;  spleen  must  be  handled  very  carefully  during  the  removal,  or 
it  may  be  ruptured. 

Paracentesis  Abdominis. — This  procedure  is  an  operation  employed 
to  remore  fluids  from  the  abdominal  cavity.  The  instruments  neces- 
sary an-  the  scalpel  and  the  trocar,  Fig.  578  being  an  admirable  ex- 
ample of  the  latter.  Fig.  579  represents  the  ordinary  form,  which 
will  meet  all  common  indications. 

The  aspirator  (Fig.  580)   is  cheap,  durable,  and  efficient.     The 


378 


OPERATIVE   SURGERY. 


handy  aspirator  of  Fitch  (581)  is  not  expensive,  and  can  be  used  in 
conjunction  with  the  canula  figured  above.     In  either  case  the  caliber 


Fig.  578.— Wood-      Fig.  579.— Trocar 
Harris  trocar.  and  canula. 


Fig.  580. — Potain's  aspirator. 


of  the  canula  should  be  small  enough  to  admit  of  the  gradual  dis- 
charge of  the  fluid,  for  if  it  be 
discharged  too  rapidly  the  dan- 
ger of  syncope  will  be  immi- 
nent. If  the  canula  be  sharp- 
pointed,  it  can  be  introduced 
without  the  aid  of  the  scalpel, 
after  the  presence  of  the  fluid 
has  been  determined  by  the  aid 
of  the  hypodermic  syringe. 

An  anaesthetic  is  not  neces- 
sary.    A  local  injection  of  a  so- 
lution of  cocaine  will  suffice  to 
relieve  all  pain  caused  by  the  in- 
Fitch's  aspirator.  troduction  of  the  needle.     The 


HOLLOW   VISCERA   IN   CONTACT   WITH   SEROUS   SURFACES.       379 


bladder  and  rectum  should  be  emptied,  and  the  abdomen  carefully  per- 
cussed to  determine  the  limits  of  dullness.  The  belly  is  then  sur- 
rounded by  a  broad,  many-tailed  bandage,  having  a  small  opening 
in  the  center  corresponding  to  the  point  of  proposed  puncture.  If 
unable  to  sit  up,  the  patient  is  placed  upon  his  side  near  to  the  edge 
of  the  bed,  but  if  his  strength  will  permit,  he  can  be  placed  in  an 
ordinary  chair,  with  the  body  bent  forward,  and  the  head  and  arms 
resting  upon  the  back  of  another  chair  in  front. 

Operation.  —  The 
instrument  is  seized 
firmly  with  the  in- 
dex-finger resting  on 
its  upper  surface  (Fig. 
582)  to  limit  the  ex- 
tent of  its  introduc- 
tion, and  is  plunged 
quickly  through  the 
wall  of  the  abdomen 
in  the  median  line, 
midway  between  the 
umbilicus  and  pubes, 
and  the  trocar  is  with- 
drawn. As  the  fluid 
escapes,  the   bandage 

is  tightened  to  facilitate  the  flow,  as  well  as  to  support  the  patient. 
The  flow  is  permitted  to  continue  until  the  fluid  is  removed,  unless 
the  patient  is  threatened  with  syncope,  when  the  trocar  is  withdrawn 
at  once.  The  puncture  should  be  closed  by  a  strip  of  adhesive  plas- 
ter, or,  better,  by  a  hare-lip  pin,  confined  in  the  usual  manner ;  the 
tails  of  the  compressing  bandages  are  then  tied  firmly  to  maintain  the 
pressure.  Care  is  taken  that  no  air  be  permitted  to  enter  the  cavity 
of  the  abdomen. 

Fallacies. — A  distended  uterus  or  bladder,  or  a  displaced  or  en- 
larged liver,  may  be  punctured. 

If  the  canula  be  sharp-pointed,  the  intestines  may  be  injured 
during  the  withdrawal  of  the  liquid.  A  blood-vessel  of  the  abdomi- 
nal walls  may  be  injured  by  its  introduction.  If  the  uterus  be  dis- 
tended from  any  cause,  the  puncture  can  be  made  through  the  right 
or  left  semilunaris  or  above  the  limit  of  the  distention. 


Fig.  582. — Introducing  trocar. 


OPBBATIOU8    APPLICABLE    TO    TIIE   VARIOUS    CONDITIONS   OF   ABDOMI- 
NAL   EEBHIA. 

The  operations  on  the  various  forms  of  hernia  that  arc  amenable 
to  operative  procedures  are:  for  the  reducible  hernia,  an  operation 

for  a  radical  cure;  for  the  strangulated,  taxis,  and   division  of  tho 


380 


OPERATIVE   SURGERY. 


Fig.  583. — Sac  of  a  hernia.     Fig.  5S4. — Sac  and  contents. 


constriction  ;  for  the  simple  irreducible  and  obstructive  forms,  the 
liberation  of  their  contents,  and  their  return  to  the  proper  situa- 
tion. 

A  hernia  may  be  defined  to  be  the  protrusion  of  a  portion  of  the 
contents  of  the  abdomen  through  any  opening  in  its  walls.  Each 
protrusion  is  composed  of  a  sac  and  its  contents,  surrounded  by  more 
or  less  of  the  tissues  composing  the  abdominal  walls.  With  but  few 
exceptions  all  hernias  possess  a  sac,  and  this  sac,  in  every  case,  is  com- 
posed of  the  parietal  peritoneum  (Fig.  583).     Only  those  viscera,  such 

as  the  caput  coil, 
colon,  bladder,  pan- 
creas, etc.,  which 
are  not  normally 
surrounded  by  this 
membrane,  can  form 
a  hernia  without  a 
sac.  The  contents 
of  a  hernial  sac,  in 
the  ordinary  sense 
of  the  term,  then 
consist  of  the  small 
intestine  and  omentum,  either  singly  or  conjointly  (Fig.  584).  If 
the  larger  viscera  escape,  it  will  be  exceptional,  and  probably  de- 
pend upon  an  abdominal  wound.  Such  a  condition  is  then  called 
a  protrusion  of  this  or  that  organ  rather  than  a  hernia  of  the  same. 
The  normal  appearance  of  the  omentum  and  small  intestines  should 
be  given  a  careful  study,  that  the  operator  may  be  able  to  determine 
the  various  degrees  of  change  in  their  appearance  when  subjected 
to  the  different  influences  associated  with  hernial  protrusions.  The 
granular  appearance  of  the  omental  fat,  together  with  its  pale  color 
and  extra  fibrous  structure,  will  distinguish  it  from  the  subserous 
tissue  fat.  The  omentum  and  gut,  while  in  the  sac,  usually  bear 
the  same  comparative  relation  to  each  other  as  in  the  abdominal 
cavity,  the  former  being  in  front.  The  sac  has  a  neck  and  a  body ; 
the  shape  and  size  of  the  latter  depend  upon  the  amount  and  density 
of  the  surrounding  tissues  and  the  nature  and  compactness  of  its  con- 
tents. The  neck  is  its  constricted  portion,  and  corresponds  to  the 
opening  through  which  it  escaped  ;  its  size  is  governed  by  the  density 
of  the  tissues  by  which  it  is  surrounded,  the  age  of  the  protrusion, 
degree  of  traction,  and  compressibility  of  its  contents.  A  knowledge 
of  the  normal  characteristics  of  the  peritoneum  is  as  essential  to  the 
surgeon  as  is  a  knowledge  of  the  peculiarities  of  the  contents  of  the 
sac.  Its  rough  outer  and  smooth  inner  surfaces,  the  arrangement  of 
its  vessels,  and  its  transparency  should  be  understood.  It  must  not 
be  forgotten,  however,  that  the  physical  appearance  of  the  sac  and  its 


HOLLOW   VISCERA  IN   CONTACT   WITH   SEROUS   SURFACES.        381 

contents  become  changed  when  long  subjected  to  the  vicissitudes  at- 
tending hernial  protrusions. 

The  tissues  composing  the  walls  of  the  protrusion,  or  the  "  cover- 
ings of  hernia,"  vary  according  to  its  situation,  rapidity  of  develop- 
ment, and  size.  While  they  may  readily  be  distinguished  in  their 
proper  places  as  component  parts  of  the  abdominal  wall,  yet,  when 
stretched  around  the  body  of  a  hernia  and  more  or  less  changed  from 
the  effects  of  pressure  and  extraneous  influences,  their  identity  often 
becomes  difficult  of  recognition. 

In  a  recent  hernia  the  cellular  tissues  and  fat  will  vary  but  little 
from  their  normal  conditions  ;  in  an  old  one,  these  tissues  will  be 
much  thinner  than  usual.  In  a  recent  protrusion  the  muscular  fibers 
of  the  cremaster  will  be  exceedingly  sparse  and  illy  developed,  while 
in  the  older  ones  the  influence  of  the  coincident  traction  will  lead  to 
their  becoming  well  developed  and  of  great  diagnostic  importance,  not 
only  as  to  the  depth  of  the  incision,  but  the  variety  of  the  protrusion. 
The  transparent  sac  often  becomes  more  or  less  opaque,  and  so  con- 
nected with  the  cellular  tissue  upon  it  as  to  be  scarcely  distinguish- 
able from  it. 

It  can  be  safely  said  that  the  changes  in  the  appearance  and  the 
anatomical  relations  of  the  component  parts  of  a  hernia,  and  the  influ- 
ences and  processes  to  which  it  is  subjected,  may  be  so  manifold  that  it 
will  present  as  varied  and  perplexing  problems,  requiring  a  speedy  so- 
lution, as  any  morbid  condition  of  the  body. 

Prior  to  attempting  any  form  of  operation  upon  a  hernia,  it  is 
necessary  that  the  surgeon  be  acquainted  with  the  important  blood- 
vessels and  their  relation  to  the  body,  and  more  especially  the  neck  of 
the  sac.  He  must  know  the  bony  landmarks,  the  ligamentous  asso- 
ciations, and  the  direction  of  the  exit,  else  he  will  be  unable  to  distin- 
guish the  variety  of  hernia  or  to  manipulate  its  return. 

OPERATIONS    FOR   RADICAL   CURE. 

Heaton's  Operation. — This  consists  in  injecting  into  the  inguinal 
canal  with  a  syringe,  constructed  for  the  purpose,  ten  or  fifteen  drops 
of  a  mixture,  composed  of  one  half  an  ounce  of  Thayer's  fluid  extract 
of  quercus  alba,  prepared  in  vacuo,  and  fourteen  grains  of  the  solid 
extract  of  quercus  alba.  Triturate  with  gentle  heat  until  the  solu- 
tion is  as  perfect  as  possible.  A  grain  of  morphia  to  the  ounce  can 
be  added  to  alleviate  the  pain  caused  by  the  injected  fluid. 

The  patient  ia  placed  on  the  back,  contents  of  the  sac  returned, 
and  if  necessary  retained  by  the  finger  of  an  assistant.  Locate  the 
nal  abdominal  ring  with  the  right,  forefinger  passed  upward  and 
outward,  inyaginating  the  scrotum  ;  press  the  left  forefinger  perpen- 
dicularly upon  the  integument  over  the  ring,  using  sufficient  force  to 
the  integument  together  with  the  finger  directly  into  i  he  ring, 


382 


OPERATIVE   SURGERY. 


thus  leaving  nothing  between  it  and  the  external  pillar  but  the  in- 
tegument and  subjacent  fascia.  The  syringe,  already  charged,  is 
taken  in  the  right  hand,  and  quickly  introduced  through  the  integu- 
ment and  fascia  into  the  inguinal  canal,  closely  hugging  the  external 
pillar.  The  forefinger  is  then  removed,  and  the  needle  carried  care- 
fully along  the  posterior  surface  of  the  aponeurosis  of  the  external 
oblique,  for  an  inch  or  so,  when  the  fluid  is  deposited,  drop  by  drop, 
in  various  portions  of  the  canal,  by  moving  the  point  around  during 
its  withdrawal.  A  small  portion  should  be  deposited  at  the  extreme 
end  of  the  canal  ;  the  intercolumnar  fascia  and  the  pillars  of  the  ex- 
ternal ring  should  be  well  medicated.  The  needle  is  then  withdrawn, 
the  opening  sealed,  compress  and  bandage  applied,  and  the  patient 
kept  in  the  dorsal  position.  If  undue  inflammation  occurs,  it  is  to  be 
treated  in  the  usual  manner.  As  a  rule,  the  pain  and  tenderness  will 
disappear  in  two  or  three  days,  after  which  the  patient  is  to  be  kept 
quiet  for  ten  days  before  attempting  to  walk,  and  then  the  part 
should  have  proper  support,  which  should  be  continued  in  use  for  six 
or  eight  weeks,  and  even  longer  in  the  interest  of  discretion. 

The  results  claimed  for  this  method  by  its  originator  have  not  been 
substantiated  by  the  trials  to  which  it  has  been  subjected  by  many 
careful  and  unprejudiced  surgeons.  It  is,  however,  devoid  of  danger, 
provided  the  fluid  be  not  thrown  into  the  peritoneal  cavity,  and  is 
rarely  followed  by  suppuration.  In  a  recent  oblique  hernia  with  a 
small  neck  it  is  a  harmless  expedient,  which  often  affords  relief.  It 
must  not  be  forgotten,  however,  that  unless  constant  caution  is  ob- 
served, the  protrusion  may  recur. 

The  percentage  of  cures  and  failures  are  about  the  same — thirty 
per  cent.     In  the  remainder  the  result  is  indifferent. 

Wiitzer's  Method. — The  protruded  parts  are  returned,  and  a  fold 
of  integument  is  pushed  as  far  as  possible  into  the  canal  with  the 

index-finger  of  the 
left  hand  ;  the 
cylindrical  portion 
of  the  instrument 
(Fig.  585)  is  well 
oiled  and  carried 
into  the  cul-de-sac, 
guided  by  the  fin- 
ger, which  is  slow- 
ly withdrawn  as 
the  instrument  is 
inserted.  The  dis- 
Fis.  585.— Wiitzer's  apparatus.  *»!     extremity     of 

the   instrument  is 
passed  up  to  the  internal  ring,  the  needle  projected,  passing  through 


HOLLOW   VISCERA   IX   CONTACT   WITH   SEROUS   SURFACES.        383 


the  neck  of  the  sac  and  tissues  of  the  abdominal  wall ;  the  concave 
cover  is  then  screwed  down  and  a  cork  fixed  on  the  end  of  the  needle. 
The  instrument  is  allowed  to  remain  in  position  eight  or  ten  days. 
After  the  removal,  the  patient  is  kept  in  bed  as  much  longer,  and  is 
then  permitted  to  get  up,  keeping  the  parts  supported  by  a  truss  for 
five  or  six  months. 

Agneii^s.  Modification. — Evacuate  the  patient's  bowels  thoroughly 
the  day  before  the  operation.  Place  him  in  a  horizontal  position,  shave 
and  cleanse  the  parts,  make  an  incision  through  the  integument,  com- 
mencing at  the  external  abdominal  ring  and  terminating  two  inches 
below  it :  separate  the  integument  from  its 
fascial  connections  at  either  side  of  the  incis- 
ion, then  invaginate  the  fascia  and  dartos, 
pushing  it  to  the  outer  extremity  of  the  canal 
by  the  index-finger,  along  which  the  instru- 
ment is  now  passed.  The  instrument  (Fig. 
586)  is  introduced  with  its  grooved  blade 
resting  internally  to  carry  the  invaginated 
integument  to  the  outer  extremity  of  the  ca- 
nal. The  blades  are  then  widely  separated, 
and  the  long  needle,  armed  with  a  silver  wire, 
is  inserted  into  one  of  the  grooves  of  the  inner 
blade,  and,  guided  by  it,  is  passed  through 
the  superimposed  tissues,  the  end  of  the  wire 
grasped,  needle  withdrawn  and  directed  by 
the  other  groove  through  the  tissues  in  the 
same  manner,  causing  the  points  of  puncture 
to  be  about  half  an  inch  apart.  The  wire 
is  then  cut  of  sufficient  length  to  be  twTisted 
around  a  piece  of  cork,  or  bent,  thus  securely 
fastening  the  apex  of  the  invagination  within 
the  canal.  The  sides  of  the  inguinal  canal 
are  now  drawn  together  by  three  transverse 
sutures  half  an  inch  apart,  introduced  by  a 
needle  armed  with  stout  silk  thread,  which 
is  passed  between  the  blades  of  the  instru- 
ment. This  should  then  be  withdrawn,  the 
wound  closed  and  dressed  antiseptic-ally,  the 
patient  confined  to  the  bed,  and  the  bowels  Fig. 580. — Agnew'a  apparatus. 
kept  closed  by  opium  to  avoid  straining. 

The  transverse  sutnres  are  allowed  to  remain  in  position  for  eight 
or  ten  day-,  the  dryer  one  somewhat  longer,  the  object  being  to  cause  a 
firm  agglutination  of  the  invaginated  plug  to  the  surrounding  tissues. 

The  results  of  this  operation  are  flattering.  If  the  cases  be  cor- 
rectly reported,  over  eighty  per  cent  are  cured. 


384 


OPERATIVE   SURGERY. 


Wood's  Method.— This  consists  in  drawing  together  and  retaining 
the  tendinous  structures  of  the  inguinal  canal  and  pillars  of  the  ring 
by  the  means  of  a  ligature,  until  the  parts  become  united  by  effused 

lymph. 

The  instruments  required  are  a  tenotome,  semicircular  needle  at- 
tached to  a  strong  handle,  and  a  silver-plated  copper  wire  (Fig.  587). 

The  method  of 
procedure  is  suc- 
cinctly portrayed 
by  Mr.  Druit  : 
"The  patient  be- 
ing tied  on  his 
back,  with  the 
shoulders  well 
raised,  with  the 
knees  bent,  the 
pubes  cleanly 

shaved,  the  rup- 
ture completely  reduced,  and  chloroform  administered,  an  oblique  in- 
cision about  an  inch  long  is  made  in  the  skin  of  the  scrotum  over  the 
fundus  of  the  hernial  sac.  The  knife  is  then  carried  flatwise  under 
the  margins  of  the  incision  so  as  to  separate  the  skin  from  the  deep 
coverings  of  the  sac,  to  the  extent  of  about  an  inch,  or  rather  more, 
all  around.  The  forefinger  is  then  pressed  into  the  wound,  and  the 
detached  fascia  and  fundus  of  the  sac  invaginated  into  the  canal  as 


Fig.  581. — Wood's  apparatus. 


— Transfixing  conjoined  tendon. 


represented  in  Fig.  588.  The  finger  then  feels  the  border  of  the  in- 
ternal oblique  muscle,  lifting  it  forward  to  the  surface.  By  this 
means  the  inner  edge  of  the  conjoined  tendon  is  felt  at  the  inner  side 
of  the  finger.     The  needle  is  then  carried  carefully  up  to  the  point  of 


HOLLOW   VISCERA   IN   CONTACT   WITH   SEROUS   SURFACES. 


38; 


the  finger  along  its  inner  side  and  made  to  transfix  the  conjoined  ten- 
don, and  also  the  inner  pillar  of  the  ring  (Fig.  589).  When  the  point 
is  seen  to  raise  the  skin,  the  latter  is  drawn  over  toward  the  median 
line,  and  the  needle  made  to  pierce  it  as  far  outward  as  possible. 

A  small  hook  is  bent  on  tbe  point  of  the  wire,  inserted  into  the 
eye  of  the  needle,  and  drawn  back  into  the  scrotum  and  detached. 
The  finger  is  next  placed  behind  the  outer  pillar  of  the  ring  and 
made  to  raise  that  and  Poupart's  ligament  as  much  as  possible  from 
the  deeper  structures.  The  needle  is  now  passed  along  the  outer  side 
of  the  linger  through  Poupart's  ligament  a  little  below  the  deep  her- 
nial opening  (Fig.  590),  and  the  point  is  then  directed  to  the  skin 


Fig.  ."90. — Transfixing  Poupart's  ligament. 


Fig.  591. — Passing  through  or  behind 
the  sac. 


puncture  before  made.  The  outer  end  of  the  wire  is  hooked  on  to 
the  needle,  and  the  wire  is  then  drawn  back  into  the  scrotal  puncture 
m  before,  and  detached. 

Next  the  sac  at  the  scrotal  incision  is  pushed  up  between  the 
thumb  and  forefinger,  and  the  cord  slipped  back  from  it,  as  is  done  in 
taking  up  varicose  veins.  The  needle  is  then  passed  across  behind  or 
through  the  Bac,  between  it  and  the  cord,  entering  and  emerging  at 
the  opposite  ends  of  the  scrotal  incision,  as  shown  in  Fig.  591.     The 

end  of  the  inner  wire  is  again  hooked  on  and  drawn    hack  behind  the 

Tie'  in*  die  may  be  made  to  pass  through  one  or  both  of  the  pil- 
lars at  the  same  time  close  to  their  insertion.      Both  end-  of  (he  wire 
20 


386 


OPERATIVE   SURGERY. 


are  then  drawn  down  until  the  loop  is  near  the  surface  of  the  groin 
above,  and  they  are  twisted  together  down  into  the  incision  and  cut  off 
at  a  convenient  length.  Traction  is  then  made  on  the  loop  so  as  to 
invaginate  the  sac  and  scrotal  fascia  well  up  into  the  inguinal  canal. 
The  loop  of  wire  is  firmly  twisted  close  down  into  the  upper  puncture 
and  bent  downward  to  be  joined  to  the  two  ends  below  in  a  bow  or 
arch,  beneath  which  is  placed  a  fine  pad  of  lint  (Figs.  592  and  593), 
and  the  whole  confined  in  position  by  a  spica  bandage. 


=^§> 


=® 


Figs.  592   593. — Invagination  completed. 


Fig.  594. — Wood's  rect- 
angular pins. 


Modification  with  Pins. — For  small  herniae  and  herniae  in  children 
Dr.  Wood  employs  a  pair  of  rectangular  pins  (Fig.  594).  With  the 
finger  in  the  inguinal  canal,  as  in  the  preceding  operation,  one  pin  is 

made  to  pass  through 
the  conjoined  tendon 
and  the  internal  pillar 
from  above  down- 
ward, and  the  other 
to  pass  through  Pou- 
part's  ligament  from 
below  upward  (Fig. 
595). 

They  should  both 
be  caused  to  enter  and 
emerge  at  the  same 
point  of  cutaneous 
puncture.      The  pins 


Fig.  595. — Passing  the  pins. 


HOLLOW   VISCERA   IX   CONTACT   WITH   SEROUS  SURFACES.        38? 


are  bent  at  a  right  augle  at  the  blunt  extremity,  the  angle  being 
looped.  After  the  transfixion  they  are  locked  to  each  other  and 
twisted  around  to  more  closely  entwine  the  included  structures. 
The  ends  of  the  pins  are  then  cut  off  and  the  blunt  extremities  are 
pressed  against  the  abdominal  wall,  con- 
fined in  position,  and  allowed  to  remain 
eight  or  ten  days  (Fig.  596).  j 

The  results  obtained  by  this  method,  as 
recorded  by  Dr.  Wood,  are  most  excellent, 
seventy  per  cent  being  satisfactory ;  be- 
tween one  and  two  per  cent  died. 

These  results  have  not,  as  yet,  been  du- 
plicated by  other  operators. 

Czerny's  Method. — Expose  the  sac  by  a 
free  incision  in  its  long  axis  and  separate 
it  from  the  surrounding  tissues,  isolate  its 
neck  and  tie  it  with  a  strong  catgut  liga- 
ture. Amputate  the  sac  below  the  liga- 
tured point,  push  the  stump  into  the  ab- 
dominal cavity,  refresh  the  borders  of  the 
opening,  and  unite  them  by  a  continuous 
catgut  ligature. 

Results. — Of  the  cases  reported  all  but 
one  resulted  in  a  satisfactory  manner.     It 

is  suggested  by  Prof.  S.  D.  Gross  that  the  method  can  be  modified  by 
simply  tying  the  sac  as  before  and  returning  it  to  the  abdominal  cavi- 
ty, which  will  expose  the  patient  to  no  unnecessary  danger. 

It  is  recommended  that  the  sac  be  twisted  after  tying  its  neck, 
to  excite  adhesive  inflammation.  The  lower  end  of  the  sac  may 
be  drawn  to  the  outer  end  of  the  inguinal  canal  by  a  ligature 
extending  from  it  through  the  abdominal  walls,  and  the  sac  is  then 
fastened  in  place  by  tying  the  ligature  around  an  antiseptic  com- 
press. 

TJie  author  has  employed  a  method  of  treating  the  sac  of  ordinary- 
sized  herniae,  which  he  has  not,  as  yet,  seen  described.  After  the 
neck  of  the  sac  is  tied,  a  looped  ligature  armed  with  a  large  needle  is 
carried  through  flu:  lower  extremity  and  tied.  Two  parallel  incisions 
are  then  made  half  an  inch  apart,  the  lower  one  being  made  half  an 
inch  above  the  border  of  the  internal  pillar.  They  should  correspond 
in  length  to  the  width  of  the  sac.  The  externa]  pillar  is  treated  as 
nearly  a-  possible  in  the  same  manner  ;  the  first  incision  being  located 
a  little  below  its  upper  border.  The  sac  is  first  carried  upward  behind 
the  internal  pillar,  drawn  through  the  upper  slit,  and  returned  through 
the  lower  slit  of  the  same  pillar ;  then  it  is  carried  behind  the  external 
pillar,  out  through  its  upper  slit,  and  returned  again  by  being  poshed 


Fig.  596. — Pins  in  position. 


388  OPERATIVE   SURGERY. 

inward  through  the  lower  slit  of  the  pillar.  The  sac  is  drawn  tight- 
ly, the  borders  of  the  external  ring  are  approximated  and  sewed  with 
catgut  or  silver  wire,  the  stitches  being  carried  through  the  walls 
of  the  sac  lying  beneath.  This  "  weaving "  process  not  only  thor- 
oughly closes  the  external  abdominal  ring,  but  also  introduces  ad- 
ditional layers  of  peritoneum  in  front  of  the  weakened  point  of  the 
abdominal  wall. 

Results. — Sufficient  time  has  not  yet  elapsed  since  the  first  opera- 
tion performed  by  this  plan  to  admit  of  a  positive  expression  of  opin- 
ion regarding  the  result. 

Dowell's  Method. — Prepare  the  patient  as  in  the  preceding  methods. 
He  is  then  placed  in  a  recumbent  posture  with  the  shoulders  elevated 
and  the  limbs  flexed. 

Operation. — Be  sure  the  hernia  is  reduced.  Invaginate  the  scrotal 
tissues  with  the  index-finger.  Take  the  semicircular  needle,  especially 
designed  for  the  purpose,  and  arm  it  with  a  strong  silken  ligature. 
The  needle  is  entered  one  inch  and  a  half  above  the  external  ring 
and  passed  beneath  and  close  to  the  tip  of  the  finger  and  brought  out 
through  the  skin  on  the  opposite  side,  near  to  Poupart's  ligament. 
This  stitch  passes  through  the  integument,  the  aponeurosis  of  the  ex- 
ternal oblique,  and  the  hernial  sac  near  the  posterior  wall  of  the  canal. 
The  needle  is  withdrawn  till  its  point  is  disengaged  from  the  tendon, 
and  is  then  carried  over  the  point  of  the  finger  in  close  contact  with 
it,  and  pushed  through  the  first  puncture,  situated  near  to  Poupart's 
ligament.  By  this  procedure  the  loop  is  made  to  surround  the  In- 
guinal canal,  and  both  its  extremities  lie  together  in  the  primary 
puncture.  To  one  end  of  the  silken  ligature  just  passed  attach  a  sil- 
ver wire  which  is  then  drawn  into  the  position  of  the  former.  Two 
or  more  silver  wires  are  introduced  in  a  similar  manner  at  different 
situations  along  the  canal.  Each  of  these  is  then  twisted  over  a 
cylinder  of  antiseptic  gauze  placed  upon  the  abdomen  and  the  whole 
is  dressed  antiseptically.  The  patient  should  be  kept  quiet  in  bed  for 
eight  or  ten  days,  upon  a  restricted  diet,  after  which  the  stitches  can 
be  removed  ;  and  the  patient  allowed  to  walk,  three  or  four  days  later. 

Results. — Dr.  Dowell  some  time  since  reported  ninety-six  cases 
treated  in  this  manner,  with  eighty  cures  and  sixteen  failures. 

In  many  cases  of  the  so-called  radical  cures  obtained  by  any  method, 
the  fondest  anticipations  of  the  patient  and  surgeon  are  too  often  dis- 
pelled by  the  return  of  the  protrusion.  To  avoid  this,  if  possible,  an 
easy-fitting  truss  should  be  worn  for  a  long  time  afterward.  The 
direct  methods  can  be  employed  in  the  treatment  of  all  forms  where 
the  neck  of  the  sac  can  be  reached  and  the  borders  of  the  opening  ap- 
proximated. 

Radical  Cure  of  Femoral  Hernia  (Wood).— The  same  instruments 
are  required  for  operation  upon  femoral  hernia  as  upon  inguinal.    The 


HOLLOW   VISCERA   IN   CONTACT   WITH   SEROUS   SURFACES.        389 

patient  is  placed  on  the  back  with  shoulders  well  elevated,  and  an  inci- 
sion an  inch  in  length  is  made  in  the  long  axis  of  the  protrusion 
through  the  integument.  The  subjacent  fascia  is  separated  from  the 
integument  and  is  pushed  into  the  femoral  opening  with  the  index- 
finger,  which  is  placed  at  the  inner  side  of  the  femoral  vein  to  protect 
it.  The  needle  is  passed  upward  through  the  sac,  and  is  directed  so 
as  to  include  with  it  the  pubic  portion  of  the  fascia  lata  over  the  pec- 
tiueus  muscle  (Fig.  597,  b).  The  point  of  the  needle  appearing  at 
the  wound  is  then  pushed  upward  and  through  Poupart's  ligament 
toward  the  nail  of  the  invaginating  finger.  The  skin  of  the  groin  is 
drawn  outward  and  pierced  by  the  needle.  A  wire  is  passed  through 
the  eye  of  the  needle  and  is  carried  downward  by  its  withdrawal.  The 
wire  is  removed  and  left  in  the  wound,  and  the  needle  again  carried 
through  the  pubic  portion  of  the  fascia  lata  about  an  inch  outside  of 
its  preceding  course,  and  upward  through  the  falciform  process  of  the 
fascia  lata  and  Poupart's  ligament  through  the  integumentary  punct- 
ure previously  made  (Fig.  597,  a).  The  other  end  of  the  wire  is 
then  inserted  into  the  needle  and  pulled  down  as  before.  The  lower 
ends  are  then  twisted  together  in  the  incision,  the  twisted  end  cut  off 
five  or  six  inches  long,  and  the  upper  external  loop  twisted  firmly  down 
upon  the  integument  (Fig.  598)  and  looped  as  before  (Fig.  599). 


Fio.  697.— Passing  noodle  through  fascia  lata.      Fio.  598. — Wire  in  position  for  twisting. 

Umbilical  Hernia. — The  instruments  required  arc  a  stout  needle,  a 
spoon-shaped  concave  director,  and  two  pieces  of  stoul  silvered  copper 
wire,  eight  or  ten  inches  in  length  (Fig.  600).     The  patient  is  placed 


390 


OPERATIVE   SURGERY. 


on  the  back,  the  shoulders  are  raised,  the  thigh  flexed  on  the  abdo- 
men, and  the  contents  of  tumor  reduced.  The  spoon-shaped  director, 
~b,  with  its  concave  surface  uppermost,  is  pushed  into 
the  highest  portion  of  the  opening,  upon  either  the 
right  or  left  side,  carrying  the  integument  beneath 
the  free  border  of  the  tendinous  outline  of  the  open- 
ing. The  needle,  d,  is  carried  along  the  concave 
surface  and  thrust  through  the  invaginated  integu- 
ment, fibrous  border,  and  also  the  superimposed 
integument,  after  this  has  been  drawn  upward. 
The  end  of  the  wire  a,  is  then  introduced  into  the 
needle  and  drawn  through  the  puncture.  The 
lower  portion  of  the  opening  is  pierced  in  the  same 
manner,  the  skin  being  drawn  downward  to  cause 
the  needle  to  emerge  at  or  near  the  puncture  previ- 
ously made.  The  second  wire  is  then  drawn  through 
in  a  similar  manner.  The  operation  is  repeated 
on  the  opposite  side,  the  end  of  the  needle  being 
introduced,  first,  at  the  puncture  first  made  and  carried  along  beneath 
the  integument  situated  between  the  fibrous  boundaries  of  the  open- 


Eig.  599.  —  Wire 
looped  in  posi- 
tion. 


Fig  600. — Instruments  for  umbilical  hernia. 


ing,  thence  out  through  the  tendinous  border  of  the  rupture  as  before 
described.  The  extremities  of  the  wire  are  then  twisted  until  the 
opening  is  closed,  when  they  are  cut  of  a  sufficient  length  to  be 
hooked  over  a  compress  of  lint  and  retained  by  adhesive  plaster  and  a 
bandage. 

STRANGULATED  HERNIA. 

Strangulation  is  a  condition  induced  in  the  sac  by  a  constriction 
located  at  the  neck  or  within  the  sac  itself,  which  obstructs  the  circu- 
lation entirely  or  in  part,  thereby  exposing  the  contents  of  the  con- 
stricted portion  to  the  danger  of  gangrene.  The  operations  for  its 
relief  are  taxis  and  herniotomy,  the  latter  sometimes  being  called 
helotomy,  and  in  common  parlance  "an  operation  upon  strangulated 
hernia." 


IIOLLOW   VISCERA   IN    CONTACT   WITH   SEROUS  SURFACES.        391 

Taxis. — This  consists  in  returning  the  constricted  viscus  to  the  ab- 
dominal cavity  through  the  channel  of  its  escape  by  manipulation 
aided  by  force  of  gravity  and  the  relaxation  of  the  constricting  agen- 
cies. As  a  rule  it  will  be  found  that  strangulation  occurs  to  a  protru- 
sion of  long  standing,  where  the  patient  has  become  self-educated  in 
the  practice  of  returning  it.  It  therefore  follows,  when  the  case  is 
brought  to  the  attention  of  the  surgeon,  that  the  patient  has  made 
persistent  but  ineffectual  efforts  to  reduce  it ;  under  these  circum- 
stances the  outlook  for  the  surgeon's  success  is  not  brilliant.  He 
should  first  diagnosticate  the  variety  of  hernia,  that  his  efforts  may  be 
intelligently  directed  ;  also  its  condition,  that  his  efforts  may  do  no 
further  injury  to  the  parts  or  cause  harmful  procrastination.  If  mod- 
erate effort  be  not  sufficient  to  return  it,  a  hypodermic  injection  of 
morphia  may  be  given  near  the  seat  of  the  constriction,  and  the  pa- 
tient kept  in  a  warm  bath,  with  the  pelvis  elevated,  until  the  com- 
bined influences  are  felt  on  the  general  system.  It  can  thus  often  be 
returned  without  difficulty,  either  by  the  patient  or  surgeon,  the  for- 
mer being  less  liable  to  employ  harmful  force  because  of  the  pain  pro- 
duced. If  these  measures  fail,  and  if  the  strangulation  be  of  recent 
date  and  the  symptoms  not  urgent,  the  patient  is  then  thoroughly 
dried,  surrounded  by  warm  wraps,  placed  in  a  bed  with  its  foot  well 
elevated,  and  hot  applications  applied  to  the  parts.  These  measures 
are  of  themselves  often  sufficient  to  cause  its  return.  If  they  fail, 
then  taxis  is  repeated  with  or  without  an  anaesthetic.  If  an  anaes- 
thetic is  used,  it  should  be  with  the  understanding  that  a  failure  at 
reduction  will  be  followed  by  an  immediate  operation. 

Taxis  is  practiced  by  elevating  the  hips,  relaxing  the  tissues,  and 
endeavoring  to  return  the  part  first  which  escaped  last,  in  the  direc- 
tion of  the  channel  through  which  it  came.  Empty  the  bowels  and 
bladder,  flex  the  thigh  upon  the  body,  abduct  and  rotate  it  inward  to 
relax  the  muscular  and  fibrous  tissues  about  the  groin,  grasp  the  tumor 
with  the  right  hand,  and  draw  it  downward  carefully  to  disengage  its 
neck  and  at  the  same  time  to  give  to  it  the  proper  direction  for  reduc- 
tion. Gentle,  uniform,  and  continuous  pressure  is  then  made  upon  it 
by  t lie  right  hand,  while  the  thumb  and  fingers  of  the  left  steady  the 
upper  extremity.  If  successful,  in  a  few  moments  the  surgeon  will  be 
conscious  of  a  slight  gurgling  noise,  followed  by  a  diminution  in  its 
size  and  tension.  This  is  caused  by  the  escape  of  gas  or  fecal  matter, 
and  will  soon  be  followed  by  the  return  of  the  entire  protrusion. 
Properly  directed  taxis  should  not  be  continued  longer  than  fifteen  or 
twenty  minutes,  when  the  herniotomy  should  bo  proceeded  with.  If 
it  be  improperly  directed,  the  sooner  stopped  the  better. 

If  taxis  be  applied  to  a  femoral  protrusion,  if  it  be  a  complete  one, 
it  rnii-t  not,  l)f  forgotten  that  it  is  necessary  to  first  press  downward, 
and  ih' a  ij'tc/cward  and  upward.    It  not  infrequently  happens  that  a 


392  OPERATIVE   SURGERY. 

large  femoral  hernia  is  mistaken  for  an  inguinal  one,  and  efforts  are 
directed  to  returning  it  through  the  inguinal  canal. 

Kelotomy.— The  instruments  required  for  this  operation  are  the 
ordinary  scalpel,  thumb-forceps,  and  artery-forceps,  scissors,  hernial 
knife  (Figs.  601  and  602)  and  hernial  director  (Fig.  603),  hypodermic 


Figs.  601,  602.— Hernial  knives. 

syringe,  ordinary  grooved  director,  needles,  and  the  materials  for  com- 
plete antiseptic  treatment.  The  steps-  of  the  operation  may  be  logic- 
ally divided  into  six  :  1,  division  of  the  tissues ;  2,  recognition  of  the 

sac  ;   3,  opening  of 

T^.  603.— Levis'  director.  tion  of  the  contents  ; 

5,    division    of    the 
stricture  and  return  of  the  protrusion  ;  6,  closure  of  the  wound. 

Division  of  the  Tissues. — After  the  patient  is  etherized,  and  the 
parts  are  shaved  and  cleansed  by  scrubbing,  and  suitably  placed  in  a 
good  light,  an  incision  two  or  three  inches  in  length  is  made  through 
the  integument,  by  transfixion  or  otherwise,  in  the  long  axis  of  the 
tumor.  The  remaining  structures,  forming  the  wall  of  the  sac,  are 
picked  up  one  after  another  with  the  thumb-forceps  at  the  lower  angle 
of  the  wound  and  nicked,  the  grooved  director  is  pushed  beneath  each 
one,  and  it  is  then  divided  with  the  knife  or  scissors.  The  possibility 
of  recognizing  the  different  layers  will  depend  very  largely  on  the  length 
of  time  the  hernia  has  existed,  as  well  as  upon  the  amount  of  exter- 
nal irritation  to  which  it  has  been  subjected.  It  is  exceptional,  how- 
ever, when  many  of  the  layers  can  not  be  easily  recognized,  especially 
those  of  a  muscular  character  and  the  dense  fascia.  As  the  sac  is  ap- 
proached, the  question  which  will  most  annoy  the  surgeon  is,  which 
is  the  sac  ?  am  I  without  or  within  it  ?  The  sac  is  recognized  by  the 
various  layers  and  their  anatomical  characteristics  ;  the  fascia  trans- 
versalis,  which  surrounds  it  and  is  separated  from  it  by  the  fatty  sub- 
serous tissue,  is  quite  liable  to  be  mistaken  for  the  peritoneum.     The 


HOLLOW   VISCERA   IN   CONTACT   WITII   SEROUS   SURFACES.        393 


«6 


fascia  is  dense,  opaque,  non-translucent,  and  always  present.  If  a 
similar  tissue  has  not  been  divided  before,  this,  then,  can  not  be  the 
sac.  A  minute  opening  should  be  made  through  it  at  the  lower  por- 
tion of  the  wound,  a  grooved  director  passed  beneath  it,  and  its  divis- 
ion carefully  made.  The  next  layer  is  the  subserous  fat,  which  is  often 
quite  well  marked.  If  the  surgeon  with  hesitation  divides  the  fascia 
transversalis  under  the  impression  that  it  is  the  sac,  he  will  become 
somewhat  reassured  by  mistaking  the  subserous  fat  for  the  omentum 
in  the  protrusion.  This  feeling  of  security  will  be  quickly  dispelled, 
however,  when  he  attempts  to  find  the  intestine,  or  to  return  the  sup- 
posititious omentum. 

Recognition  of  the  Sac. — It  is  globular  in  form,  of  a  bluish  color, 
and  often  transparent.  A  sense  of  fluctuation  is  often  discernible 
at  its  lower  portion.  It 
can  be  pinched  up  be- 
tween the  thumb  and 
finger,  and  its  smooth 
serous  surfaces  can  be 
rubbed  together,  if  they 
be  not  adherent  to  its 
contents.  This  is  diag- 
nostic. The  intestine 
may  be  pinched  up  in 
the  same  manner  before 
the  sac  is  opened,  when  it  will  quickly  and  easily  escape  the  grasp  on 
account  of  the  smooth  opposed  serous  surfaces.  If  a  needle  be  intro- 
duced, a  drop  of  fluid  will  escape  ;  this  is  characteristic  of  a  hernial 

sac.  Finally,  if  the  membrane  be  ex- 
amined, it  will  be  found  to  surround 
and  limit  the  protrusion,  being  mova- 
ble only  as  a  whole,  denser  than  the 
intestine,  and  devoid  of  its  external 
serous  surface.  The  sac  is  now  to  be 
picked  up  with  the  thumb-forceps  at 
the  fluctuating  point,  or  the  point 
where  the  drop  of  fluid  escaped,  and 
a  small  slit  made  in  it  with  the  knife- 
point held  at  right  angles  to  the  for- 
ceps (Fig.  004).  If  fluid  be  present  it  will  then  escape.  A  grooved 
director  is  inserted  (Fig.  605)  and  an  opening  made  of  sufficient  size 
to  admit  the  index-finger,  which  is  introduced  to  determine  with  cer- 
tainty the  tissue  just  cut,  as  well  as  the  location  of  the  constriction 
(Fig.  606).  If  the  finger  be  in  the  sac,  it  will  come  in  contact  with 
smooth  surfaces,  and,  after  division  of  the  constriction,  can  be 
ed  through  the  neck  of  the  sac   into  the  abdomen.      If  the  tin- 


Figs.  604,  605. — Opening  the  sac. 


Fig.  603. — Introducing  the  finger. 


394  OPERATIVE   SURGERY. 

ger  be  without  the  sac,  it  can  not  be  passed  upward  without  being 
arrested.  The  existence  of  cysts  in  the  line  of  incision  may  con- 
fuse the  surgeon.  If,  however,  the  finger  be  introduced  into  them, 
their  non-serous  lining  and  limited  extent  will  expose  the  fallacy. 
The  sac  is  now  opened  sufficiently  to  expose  its  contents  to  a  careful 
scrutiny,  that  the  propriety  of  returning  them  may  be  carefully  con- 
sidered. 

Examination  of  the  Contents. — Under  all  circumstances  there  will 
be  more  or  less  injection  of  the  vessels.  If  the  constriction  be  recent 
or  slight,  the  changes  in  the  imprisoned  tissues  will  not  be  great ;  but 
when  severe  or  long  continued,  the  intestine  will  be  of  a  more  or  less 
purple  or  blackish  color,  with  isolated  ecchymoses.  The  bowel  may 
present  this  appearance,  and  yet  may  possess  sufficient  vitality  to  re- 
cover. The  color  is  not  of  as  much  importance  in  determining  the 
presence  of  gangrene  as  the  inability  to  restore  the  circulation  after 
division  of  the  stricture  by  the  aid  of  warm  fomentations.  If  the 
bowel  be  pricked  or  slightly  scarified  and  no  blood  flows  ;  if  sensi- 
bility be  absent  and  the  part  becomes  cool ;  if  its  luster  be  destroyed 
and  its  structure  be  softened  and  crackling,  it  should  not  be  re- 
turned. If  to  all  these  be  added  the  odor  of  gangrene,  it  should  be 
opened  to  afford  exit  to  its  contents  and  be  treated  with  warm 
fluid  carbolized  dressings.  It  is  considered  good  practice  at  the 
present  day  to  excise  a  circular  portion  of  the  intestine  correspond- 
ing to  the  gangrenous  part  and  unite  the  extremities  as  described 
under  the  head  of  enterectomy.  If  the  omentum  be  gangrenous 
or  bulky,  ligature  it  near  the  mouth  of  the  sac  and  cut  it  off ;  if 
not,  it  can  be  returned.  If  the  contents  be  adherent  to  each  other 
or  to  the  sac,  the  adhesions  may  be  ruptured  if  of  recent  date.  It  is 
often  necessary,  however,  to  sever  them  with  the  knife  or  scissors,  and 
in  doing  so,  the  vessels  should  be  ligatured  with  fine  catgut  as  soon 
as  seen.  When  the  adhesions  are  very  firm  and  limited,  the  corre- 
sponding portion  of  the  sac  may  be  dissected  off  and  returned  with 
the  bowel. 

Division  of  the  Stricture. — The  constricting  agency  may  be  with- 
out or  within  the  sac,  the  former  being  the  more  frequent  site.  If 
without,  it  may  be  divided  before  or  after  the  sac  is  opened,  the  latter 
being  the  almost  universal  custom.  If  the  hernia  be  a  small  one,  and 
strangulation  have  lasted  but  a  few  hours  without  stercoraceous  vomit- 
ing or  other  severe  symptoms,  and  be  composed  of  intestine  alone,  the 
constriction  may  be  divided  external  to  the  sac.  This  can  be  readily 
done  by  passing  beneath  the  constricted  tissues  of  the  neck  of  the  sac 
the  hernial  director  of  Levis  (Fig.  603),  which  is  cautiously  carried 
upward  until  the  constricting  band  falls  into  the  notches  at  either  side 
of  the  groove  ;  a  probe-pointed  bistoury  or  the  ordinary  hernial  knife 
is  then  carried   along   the  groove,  and  the  structure  divided  (Fig. 


HOLLOW    VISCERA   IN   CONTACT   WITII   SEROUS  SURFACES.        395 

607) ;  not  freely,  but  just  sufficiently  niched  to  permit  the  return 
of  the  intestine.  When  the  gravity  of  the  case  requires  the  con- 
striction to  be  divided  within  the  sac,  so  that  its  contents  may  be 
examined,  the  finger  is  carried  up  to 
the  point  of  the  obstruction,  followed 
quickly  by  the  director,  which  is  em- 
ployed as  in  the  preceding  instance. 
The  edge  of  the  knife  should  be  di- 
rected away  from  important  vessels 
aud  the  extent  of  the  cut  be  only  suf- 
ficient to  relieve  the  constriction.  If 
the  gut  be  gangrenous,  great  caution 
must  be  observed  in  cutting  the  band, 
or  the  adhesions  may  give  way  and 
allow  the  bowel  to  re-enter  the  abdom- 
inal cavity.  If  gangrene  of  the  gut  be  assured,  it  is  better  not  to 
divide  the  constriction,  since  to  do  so  not  only  exposes  the  patient 
to  the  danger  of  the  return  of  the  gangrenous  gut  into  the  abdomi- 
nal cavity,  but  also  to  the  entrance  of  discharges  from  the  wound. 
As  soon  as  the  bowel  is  returned,  stop  all  hemorrhage,  unite  the 
wound  with  catgut  carried  through  the  sac,  introduce  a  drainage- 
tube,  apply  a  compress,  dress  antiseptically,  raise  the  foot  of  the  bed, 
and  quiet  the  patient  with  an  opiate. 


Fig.  607. 


-Dividing 

tiou. 


the  constric- 


]  m;s.  008,  009. — Oblique  inguinal  hernia. 

Strangulated  Inguinal  Hernia.— A  hernia  in  this  situation  may  be 
direct  or  indirect,  either  of  which  may  be  complete  or  incomplete.  In 
the  indirect  or  oblique  form  (Figs.  608  and  609),  if  it  be  a  complete 
hernia,  it  enters  at  the  internal  abdominal  ring,  passes  downward  and 


396 


OPERATIVE   SURGERY. 


forward  to,  and  through,  the  external  ring.  The  constricting  agent 
external  to  the  sac  may  be  located  at  either  the  internal  or  external  ab- 
dominal rings,  and  rarely  in  the  inguinal  canal.  The  manner  of  cutting 
down  upon  the  sac,  and  of  detecting  and  dividing  the  constriction,  is 
described  under  the  general  considerations.  If  the  seat  of  the  constric- 
tion be  at  the  internal  ring,  it  should  be  divided  upward  and  outward 
to  avoid  the  epigastric  artery  which  runs  along  its  inner  border  (Figs. 
609,  4  and  610).     In  fact,  in  the  oblique  variety  the  incision  upward 


Fig.  610. — Course  of  epigastric  artery. 


and  outward  is  always  to  be  made  irrespective  of  the  situation  of  the 
constriction.  The  only  fallacy  that  may  arise  is  that  of  mistaking  the 
direct  for  the  indirect  form.  In  recent  cases  this  can  hardly  occur, 
but  in  those  of  long  standing,  where  the  traction  upon  the  neck  of 
the  sac  of  the  oblique  form  has  drawn  it  inward  in  front  of  the  point 
of  the  exit  of  the  direct  variety,  it  is  quite  difficult  and  often  impossi- 
ble to  distinguish  between  them.  If  the  neck  of  an  oblique  hernial 
sac  be  dragged  inward,  it  causes  the  epigastric  vessels  to  be  pressed  di- 
rectly against  its  inner  and  also  to  encroach  upon  its  upper  and  lower 
borders.  Under  these  conditions,  if  the  stricture  be  divided  agreeably 
to  directions  often  given — parallel  with  the  course  of  the  epigastric 
vessels — or  even  upward  and  slightly  outward,  these  vessels  will  be  in 
imminent  danger  of  injury. 

If,  upon  the  other  hand,  the  protrusion  be  of  the  direct  variety, 
and  the  incision  be  made  upward  and  outward,  under  the  impression 
that  it  is  a  displaced  indirect  form  of  hernia,  the  epigastric  vessels  will 


HOLLOW   VISCERA   IN   CONTACT   WITH   SEROUS   SURFACES.        397 


Fig.  611. — Direct  injruiual  hernia. 


then  be  exposed  to  peril  (Fig.  611,  G).  It  is  readily  seen,  therefore, 
that  great  caution  should  be  employed  in  distinguishing  between  the 
two,  prior  to  cutting  the  constriction. 
It  is  practically  impossible  to  discrim- 
inate between  them  until  the  coverings 
of  the  sac  are  examined.  The  oblique 
variety  has  for  a  covering  the  cremaster 
muscle,  which  can  readily  be  distin- 
guished in  an  old  hernia.  This  muscle 
never  forms  the  covering  of  a  direct 
hernia  except  when  it  passes  to  the 
outer  side  of  the  conjoined  tendon  ; 
then  its  coverings  are  similar  to  those 
of  the  oblicpie  form.  It  therefore  fol- 
lows, from  the  anatomical  relations, 
that  when  the  cremaster  does  not  form 
a  covering  the  constriction  should  be 
divided  upward  and  inward — that  is, 
away  from  the  epigastric  vessels.     If  it 

forms  one  of  the  coverings,  then  the  constriction  must  be  cut  upward 
and  outward,  provided  there  be  no  evidence  that  it  is  a  direct  hernia 
which  has  escaped  to  the  outer  side  of  the  conjoined  tendon.  This 
latter  condition  of  affairs  is  fortunately  rare,  and  this  fact,  when  taken 
in  connection  with  the  location  of  the  tumor  at  its  incipiency,  should 
settle  the  question  between  the  two.  If,  however,  it  be  impracticable 
to  settle  the  doubt,  dull  the  edge  of  the  knife  by  drawing  it  across  a 
nail  or  stone,  and  then  proceed  carefully  to  nick  the  neck  of  the 
constriction  in  an  upward  direction.  If  the  constriction  be  at  the 
external  abdominal  ring,  it  matters  little  in  which  direction  the  cut  is 
made  ;  however,  to  simplify  matters,  the  direction  upward  and  out- 
ward should  still  be  adhered  to.  The  methods  of  examination  of  the 
contents  of  the  sac  and  their  reduction,  together  with  the  subsequent 
treatment,  are  sufficiently  considered  in  the  preceding  pages.  If  the 
protrusion  be  incomplete,  the  treatment  is  similar,  and  the  matter 
simplified  by  the  inability  to  confound  the  direct  with  the  indirect 
varieties  of  this  form. 

Strangulated  Femoral  Hernia. — The    protrusion  in  this  instance 

pes  at  the  femoral  or  crural  ring  at  the  inner  side  of  the  femoral 

vein  (Fig.   618),  then  passes  along  between  the  vein  and  (iiinbernat's 

ligament,  and    the   inner   boundary  of  the  femoral  canal  for  about, 

half  an   inch,  to  t  he   upper  port  ion  of  t  he  saphenous  opening  through 

which  it  escapes,  and  in  many  instances  passes  upward  and  rests  upon 
the  falciform  process  of  thai  opening  (Fig.  613).  The  two  com- 
mon points  of  constriction  are:  Gimbernat's  ligament,  and  the  sharp 
border  of  the  falciform  process  of  the  saphenous  opening.     The  im- 


398 


OPEEATIVE   SURGERY. 


portant  boundaries  of  the  upper  extremity  of  the  crural  canal  are  : 
within,  Gimbernat's  ligament,  and  without,  the  femoral  vein,  sur- 


/  / 

Fig.  612. — Location  of  the  femoral  canal. 

rounded  by  its  sheath.  Throughout  the  course  of  this  canal  the 
femoral  vein  lies  at  the  outer  side.  The  distinctive  coverings  of  this 
protrusion  are  :  the  cribriform  fascia,  crural  sheath,  and  septum  cru- 
rale,  together  with  the  subserous  tissues.  The  important  vascular 
relations  are  those  of  the  femoral  vein  and  the  obturator  artery.  Tax- 
is should  not  be  employed  in  femoral  hernia  as  long  as  in  inguinal, 
since  the  constricting  influences  are  greater,  and  the  neck  of  the  sac 
much  smaller.  I  must  again  refer  to  the  fact  that  a  femoral  hernia, 
which  extends  upward  toward  Poupart's  ligament,  sometimes  reaching 
above  it,  may  be  mistaken  for  one  of  the  inguinal  variety,  and  that  the 
efforts  at  reduction  are  directed  to  returning  it  through  the  external 
abdominal  ring,  instead  of  pushing  it  downward,  backward,  and  up- 
ward, as  is  necessary  to  effect  a  reduction. 

Operation. — The  part  should  be  washed,  shaved,  and  disinfected  ; 
patient  placed  on  the  back,  thigh  flexed  and  rotated  outward,  bladder 


HOLLOW   VISCERA   IN   CONTACT   WITH   SEROUS  SURFACES.        399 

emptied,  patient  anaesthetized,  and  an  incision  made  in  the  long  axis 
of  the  tumor.     The  integument  and  superficial  fascia  should  be  care- 


Fig.  613. — Saphenous  opening. 

fully  divided,  thus  exposing  the  cribriform  fascia,  which  in  fleshy 
subjects  is  loaded  with  fat.  This,  with  the  glands  connected  with  it, 
especially  if  the  latter  be  enlarged,  forms  a  mass  often  difficult  to  un- 
derstand. The  glands  should  be  pushed  aside,  and  the  remainder  of 
the  structure  carefully  divided.  It  can  hardly  be  mistaken  for  any- 
thing but  the  omentum,  or  the  deeper  layer  of  fatty  tissues.  The 
absence  of  the  sac  will  readily  expose  the  fallacy  of  the  former,  and 
the  nature  of  the  latter  will  be  soon  recognized. 

The  femoral  or  crural  sheath  comes  next  in  order.  It  is  dense, 
like  the  fascia  transversalis,  of  which  it  is  a  prolongation,  and  might 
be  mistaken  for  the  sac  did  it  not  present  those  appearances  of  a  dif- 
ferent character,  which  have  already  been  described.  The  septum  cru- 
rale,  if  the  protrusion  be  large,  will  hardly  form  one  of  its  coverings; 
if  it  does,  its  texture  will  bo  much  diminished  in  thickness,  and  some- 
what hlf-nded  with  the  subserous  tisane.  It  sometimes  happens  that 
the  small  lymphatic  gland,  which  normally  exists  lid  ween  the  Bubserons 
ie  and  the  septum  crurale,  can  be  distinguished,  which,  of  course, 


400 


OPERATIVE   SURGERY. 


Figs.  614,  615. — Course  of  obturator  artery. 


settles  all  doubts  as  to  the  identity  of  the  tissues  under  inspection. 
The  careful  use  of  the  knife  and  director  soon  exposes  the  sac  with 
its  characteristic  appearance.  It  should  be  opened  at  the  lower  ex- 
tremity with  the  precautions  previously  enjoined,  and  the  stricture 
sought  for  and  divided.  If  it  be,  as  is  usual,  at  the  free  border  of  the 
falciform  process,  flex  the  thigh,  rotate  it  inward,  and  then,  if  it  is 
proper,  and  no  further  obstruction  exists,  the  protrusion  can  be  re- 
duced. If  the  constriction  be  at  the  free  border  of  Gimbernat's  liga- 
ment, this,  too,  must  be  nicked.     It  is  necessary  to  remember,  before 

attempting  this, 
that  the  obtura- 
tor artery,  once 
in  three  and  one 
half  cases,  arises 
from  the  epigas- 
tric, and  al- 
though it  usual- 
ly lies  in  contact 
with  the  vein  in 
its  descent  (Fig. 

614),  and  is,  therefore,  out  of  danger,  yet  it  not  infrequently  curves 
inward  along  the  free  margin  of  Gimbernat's  ligament  (Fig.  615),  thus 
nearly  encircling  the  neck  of  the  sac,  and  is  therefore  in  great  danger 
of  being  cut.  The  knife  should  be  made  quite  dull,  and  the  ligament 
nicked  superficially  in  several  places.  The  tip  of  the  little  finger  may 
then  be  inserted  and  the  artery  felt  for  ;  if  not  discovered,  the  nicking 
may  be  repeated,  or  firm  traction  with  the  finger  against  the  ligament 
may  be  made,  so  as  to  tear  or  stretch  it.  This  vessel  has  been  severed 
ten  or  twelve  times  during  the  operation,  but  in  each  instance  the 
bleeding  was  controlled  without  a  fatal  result.  Ligation  and  com- 
pression were  the  principal  expedients  resorted  to.  After  the  return 
of  the  protrusion,  the  wound  is  closed  and  dressed  antiseptically. 

Femoral  herniee  do  not  always  follow  the  course  just  described  ; 
they  take,  though  rarely,  anomalous  courses,  sometimes  appearing  at 
the  outer  side,  or  behind  the  femoral  vessels.  They  have  been  known 
to  pass  through  Gimbernat's  ligament.  It  is  important  to  know  that 
in  all  the  anomalous  cases  the  neck  of  the  sac  lies  closely  associated 
with  the  epigastric  artery  alone,  or,  together  with  the  obturator,  and 
troublesome  and  often  fatal  haemorrhages  may  be  caused  unless  care 
is  taken  in  dividing  the  constriction. 

Strangulated  Umbilical  Hernia. — If  the  symptoms  be  not  urgent, 
it  is  recommended  that  taxis  be  continued  longer  in  umbilical  hernia 
than  is  considered  admissible  in  other  forms  of  hernial  strangulation, 
owing  to  the  greater  death-rate  attending  herniotomy  in  this  situation. 
In  the  employment  of  taxis  the  patient  lies  upon  the  back,  with  the 


OPERATIONS  UPON  THE  ANUS  AND  RECTUM.        401 

shoulders  raised  and  the  thighs  flexed.  The  location  and  size  of  the 
opening  can  often  be  defined  by  the  finger  before  the  viscus  is  returned. 
The  seat  of  the  strangulation  is  usually  at  the  upper  border  of  the  open- 
ing. The  taxis  pressure  should  be  directed  upward  and  backward  to  cor- 
respond to  the  line  of  its  escape.  The  incision  for  the  operation  is  made 
to  suit  the  shape  and  size  of  the  tumor.  All  the  tissues  are  divided 
on  a  director,  and  the  upper  border  of  the  opening  sought  for,  since 
it  is  at  this  situation  that  the  constriction  is  most  frequently  seated. 
If  it  be  possible,  the  stricture  should  be  divided  without  opening  the 
sac,  and  the  contents  returned,  if  they  be  not  gangrenous.  If  the 
stricture  be  without  the  sac  and  the  contents  in  an  uncertain  condi- 
tion, a  small  opening,  just  large  enough  to  admit  of  inspection,  can 
be  made  through  the  sac.  If  the  stricture  be  within,  the  only  recourse 
is  to  relieve  it  through  as  small  an  opening  in  the  sac  as  possible.  If 
the  intestine  be  gangrenous,  the  constriction  must  not  be  divided,  for 
to  do  so  will  allow  the  wound  discharges  to  run  into  the  abdominal 
cavity,  even  though  the  intestine  remain  outside. 

Strangulated  Obturator  Hernia. — The  viscus  follows  the  course  of 
the  obturator  vessels  in  its  escape  from  the  pelvis,  and  lies  beneath 
the  pectineus  and  obturator  muscles.  It  is  usually  small  and  not  de- 
tected during  life. 

The  incision  for  it3  relief  is  made  over  the  tumor  at  the  inner  side 
of  and  parallel  to  the  femoral  vessels.  The  constriction  has  been 
found  in  the  fibers  of  the  pectineus  muscle  ;  and  it  is  usually  neces- 
sary to  divide  some  fibers  of  this  muscle  in  order  to  expose  the  open- 
ing through  which  it  has  escaped.  The  relation  of  the  obturator  ves- 
sels to  the  neck  of  the  sac  varies,  being  equally  frequent  at  the  outer 
and  inner  sides ;  never  in  front,  and  occasionally  behind  it.  If  the 
constriction  be  found  at  the  foramen,  it  will  require  much  caution  to 
divide  it  without  implicating  these  vessels. 


CHAPTER  XV. 
OPERATIONS   UP  OX  THE  ANUS  AND  RECTUM. 

Examination  of  the  Anus. — Place  the  patient  in  either  one  of  four 
position!  :  1,  in  the  knee  and  elbow  position  ;  2,  upon  the  back;  3, 
upon  the  right  side,  with  the  knees  drawn  upon  the  abdomen  ;  4,  or 
can--  the  patient  to  kneel  upon  a  chair  and  lean  over  its  back. 

The  position  most  commonly  employed  is  upon  the  back  in  the 
lithotomy  attitude.  The  one,  however,  which  is  most  comfortable  and 
26 


402 


OPERATIVE   SURGERY. 


at  the  same  time  most  delicate,  is  upon  the  side.  It  is  hardly  neces- 
sary to  add  that  the  surgeon  should  be  familiar  with  the  normal  char- 
acteristics of  the  parts,  not  those  alone  relating  to  the  appearances, 
but  to  their  sensibility  and  density  as  well.  On  inspection,  not  only 
will  the  presence  of  the  anal  opening  be  noticed,  but  the  wrinkled 
appearance  of  the  contiguous  integument,  the  condition  of  the  blood- 
vessels bordering  upon  it,  but  also  the  white  line  at  the  muco-cuta- 
neous  junction  will  be  seen,  which  indicates  the  interval  between  the 
internal  and  external  sphincters.  The  instruments  necessary  to  prop- 
erly examine  the  anus  and  rectum  consist  of  variously  formed  specula 
constructed  for  that  especial  purpose,  which  may  often  be  wisely  sup- 
plemented by  those  intended  for  vaginal  examinations  (Figs.  616,  617, 


Fig.  616. — Bivalve  specu-    Fig.  617. — Williams'  rec- 
lum.  tal  speculum. 


Fig.   618. — Allingham's   rectal 
speculum. 


and  618).  Sims'  speculum,  or  a  simulated  pattern  of  it,  made  by 
bending  the  handle  of  an  ordinary  tablespoon  at  a  suitable  angle,  will 
be  found  to  be  of  much  use.  Any  form  of  speculum  which  possesses 
ample  power  of  adjustment  will  serve  the  purpose  well. 

Imperforate  Anus. — This  condition  depends  upon  a  layer  of  tissue 
of  variable  thickness  which  exists  between  the  normal  site  of  the  ex- 
ternal opening  and  the  lower  extremity  of  the  rectum.  It  may  be 
simply  a  thin  layer  of  fibro-cellular  tissue,  which  by  its  projection  in- 
dicates the  nearness  of  the  loaded  bowel.  In  these  cases,  the  emotions 
of  the  child  may  be  noted  by  the  movements  of  the  interposed  mem- 
brane, and  a  positive  diagnosis  can  be  made  by  a  hypodermic  puncture. 
If  the  septum  be  thin,  a  longitudinal  or  crucial  incision,  or  even  a 


OPERATIONS   UPON   TI1E   ANUS   AND   RECTUM. 


403 


Fig.  619. — Absence  of  anus. 


simple  puncture,  followed  by  the  careful  introduction  of  a  well-oiled 
finger,  will  be  a  sufficient  operative  interference,  especially  if  after- 
ward the  extremity  of  a  suitable 
sized  rectal  bougie  be  occasionally 
introduced.  If  the  membrane  be 
of  sufficient  density  to  interpose  an 
obstacle  after  its  division,  it  should 
be  trimmed  away,  care  being  taken 
to  not  include  the  proper  structure 
of  the  opening. 

Absence  of  the  Anus  (Fig.  619). 
— In  this  deformity  all  trace  of  the 
opening  is  absent ;  and  the  median 
raphe  may  extend  continuously  from 
the  scrotum  to  the  tip  of  the  coc- 
cyx. The  fibro-cellular  interval  may 
be  thin  or  of  extreme  thickness.  If 
thin,  the  previously  detailed  signs 
of  imperforate  anus  may  be  evident. 

If  they  be  not  present,  the  occlusion  is  then  of  considerable  thickness, 
and  may  even  involve  the  entire  length  of  the  rectum  itself. 

The  operation  for  its  relief  consists  in  first  placing  the  patient, 
properly  anaesthetized,  in  the  dorsal  position.  Then  introduce  a  sound 
into  the  bladder,  if  the  patient  be  a  male,  into  the  vagina  if  a  female, 
and  make  a  vertical  incision  in  the  median  line  from  just  behind  the 
scrotum  or  vagina  to  the  tip  of  the  coccyx,  continue  it  cautiously 
upward  and  backward,  shortening  each  succeeding  cut,  and  carefully 
feel  for  the  fluctuating  extremity  of  the  gut.  It  is  sometimes  located 
posterior  to  the  central  line  and  must  be  sought  for  near  the  hollow  of 
the  sacrum.  During  the  entire  progress  of  the  dissection  the  situation 
of  the  vagina  or  urethra  must  be  marked  by  the  location  of  the  sound 
previously  introduced.  When  the  dark-brown,  fluctuating  extremity 
of  the  gut  is  detected,  the  introduction  of  a  hypodermic  needle  will 
settle  all  doubt.  The  gut-end  should  then  be  seized  by  a  pair  of  strong 
toothed  forceps  (Fig.  020),  and  drawn  firmly  downward,  while  its  con- 
nections with  the  surrounding  tissues  are  separated  by  the  scissors  and 
fingers.  As  soon  as  the  cul-de-sac  is  drawn  down  to  a  level  with  the 
mill  opening,  pass  two  short  ligatures  transversely  through  the 
-id'-  of  the  wound,  one  through  its  anterior  and  one  through  its  pos- 
terior portion,  transfixing  the  anterior  and  posterior  portions  oi*  the 
bowel  in  their  passage.  Protect  the  raw  surfaces  with  lint  saturated 
with  carbolized  oil,  then  open  the  sac  between  the  ligatures  and  allow 

it3  content-  to  •■-cape  ;  after  having  thoroughly  Cleansed  it.  remove  the 
li.it.  dra  v  the  ligature-  through  the  opening  in  the  howel  by  means  of 

a  hook,  cut  and  tie  them,  as  in  the  operation  for  lumbar  colotomy. 


404: 


OPERATIVE   SURGERY. 


The  mucous  membrane  should  be  closely  adjusted  to  the  integument, 
in  order  to  secure  perfect  union  and  prevent  the  contact  of  the  raw 


Fig.  620. — Byrne's  rectal  forceps. 

surfaces  with  the  discharges.  If  it  be  impossible  to  draw  the  end  of 
the  gut  down  to  the  external  opening,  it  can  be  incised  at  its  lower 
extremity,  and  the  discharges  allowed  to  escape  over  the  lower  sur- 
faces, which  are  kept  opened  by  the  use  of  the  bougies  ;  or,  the  coc- 
cyx can  be  removed,  as  recommended  by  Verneuil,  and  the  extremity 
of  the  bowel  drawn  through  the  gap  and  united  to  the  integument  as 
before. 

Fistula  in  Ano. — A  fistula  here,  as  elsewhere,  is  a  sinus,  which  in 

this  case  leads  into  the  cavity  of  an  ab- 
scess located  near  to  the  rectum.  It 
may  be  either  complete  or  incomplete  ; 
if  of  the  latter  variety,  it  may  be  an  in- 
complete internal  or  external  ristula 
(Fig.  621).  The  complete  form  is  the 
most  frequent.  In  the  case  of  a  sus- 
pected fistula,  before  making  an  exami- 
nation evacuate  the  bowel  by  a  cathartic 
and  an  enema  ;  place  the  patient  on  the 
back  or  side,  and  introduce  the  well- 
oiled  index-finger  of  the  hand  corre- 
sponding to  the  side  of  the  patient  pre- 
senting the  external  opening.  The  end 
of  the  finger  will  often  detect  a  nipple- 
like projection  in  the  bowel,  indicating 
the  internal  opening.  If  a  flexible  probe 
be  then  introduced  through  the  external  opening,  it  can  with  a  little 
care  be  carried  into  the  lumen  of  the  rectum  (Fig.  622).     Sometimes, 


Fig.  621.-^4,  R.  Anus  and  rectum. 
B.  Complete  fistula.  C.  Incom- 
plete internal  fistula.  D.  Incom- 
plete external  fistula. 


OPERATIONS  ON  THE  ANUS  AND  RECTUM. 


405 


however,  the  end  of  the  probe  will  be  felt  separated  from  the  finger  by 
only  the  thin  mucous  lining  of  the  gut ;  this  may  be  due  to  the  inabil- 
ity to  find  the  internal  opening,  or  to  its  non-existence.  In  either  case 
the  thin  wall  should  be 
perforated  by  the  instru- 
ment, thus  producing  a 
complete  fistula.  It  not 
infrequently  happens  that 
more  than  one  opening,  E, 
F,  communicates  with  the 
original  abscess  (Fig.  G2'6, 
D),  and  also  that  the  mu- 
cous membrane  is  under- 
mined to  a  considerable  ex- 
tent above  a  previously  ex- 
isting abscess  (Fig.  624,  A). 
It  is  of  importance  to  re- 
member that  the  introduc- 
tion of  the  finger  and  the 
probe  often  produces  such  a 
degree  of  contraction  of  the 
sphincter  as  to  prevent  the 
passage  of  the  probe  with- 
out great  difficulty  along 
the  sinus  into  the  gut ;  therefore  the  attempt  to  pass  it  should  not 
be  made  until  the  muscular  contraction  ceases.  It  may  be  advisa- 
ble to  paralyze  the 
sphincter  by  over- 
distention  before  di- 
viding the  sinus  ; 
this  causes  the  parts 
to  remain  at  rest, 
adding  to  the  com- 
fort of  the  patient 
and  hastening  re- 
covery. It  can  be 
accomplished  by  in- 
serting the  thumbs 
through  the  anus 
back  to  back,  flexing 
the  first  joints  ami 
withdrawing  them, 
or  by  the  use  of  a 
speculum  designed  for  that  additional  purpose  (Fig.  G25). 

The  accepted  method  of  treatment,  namely,  that  of  laying  open 


Fig.  622. — Probing  a  fistula. 


Figs.  828,  024.— Variations  of  fistula  in  ano. 


406 


OPERATIVE   SURGERY. 


the  sinus,  can  be  practiced  by 
direct  incision,  by  ligature,  or 
by  the  galvano-cautery.  The 
first  method  is  the  one  most 
commonly  employed.  For  this 
purpose  the  bowel  should  be 
thoroughly  evacuated  by  a  brisk 
cathartic  on  the  day  preceding 
the  operation,  and  be  followed 
by  light  diet.  On  the  day  of 
the  operation  it  should  be  thor- 
oughly cleansed  by  one  or  two 
copious  enemata. 

Operation  by  Direct  Incis- 
ion.— Place  the  patient  on  the 
back,  give  an  anaesthetic,  pass 
the  finger  into  the  bowel  as  be- 
fore described,  introduce  a  grooved  director  through  the  sinus  into 
the  bowel ;  if  the  end  can  be  turned  out  (Fig.  626),  then  divide  the 
sinus  upon  it ;  if  not,  press  it  against  the  finger,  and  pass  a  probe- 
pointed  bistoury  along  the  groove  into  the  bowel ;  after  which,  the 
director  may  be  withdrawn,  the  point  of  the  bistoury  pressed  against 
the  finger  (Fig.  627),  and  the  sinus  cut  outward  with  the  point  thus 
j>rotected.  The  finger  may  be  replaced  by  a  wooden  director  intro- 
duced into  the  bowel,  and  the  division  made  upon  it  (Fig.  628).     The 


Fig.  625. — Thebaud's  dilating  speculum. 


Figs.  626,  627,  628.— Dividing  fistulas. 

scissors  may  be  employed  instead  of  the  knife,  either  with  or  without 
the  grooved  director  (Fig.  629).  Whenever  the  depth  of  the  sinus  de- 
mands the  division  of  the  entire  thickness  of  the  internal  sphincter, 
it  should  be  done  at  right  angles  with  the  course  of  the  fibers,  to 
avoid,  as  far  as  possible,  the  danger  of  incontinence  of  flatus  and  faeces. 
While  each  sinus  should  be  opened,  still,  when  possible  to  avoid 
it,  the  sphincter  should  be  divided  in  but  one  situation,  in  order  that 
its  integrity  can  be  the  better  restored  ;  and,  when  practicable,  a  small 
portion  of  the  circular  fibers  should  be  preserved  with  the  same  object 


OPERATIONS   OX   THE   ANUS   AND   RECTUM. 


407 


Fig.  629. — Allingham's  scissors  and  director. 


in  view.  It  is  not  necessary  to  divide  the  walls  of  the  abscess  above 
the  opening  into  the  gut,  since  the  drainage  and  loss  of  power  due  to 
the  division  of  the  tissues  below  permits  a  rapid 
healing  of  this  portion.  As  soon  as  the  sinuses 
are  opened,  their  pseudo-membranous  linings  can 
be  scraped  or  touched  with  a  thermo-cautery,  all 
hemorrhage  stopped,  the  cut  packed  with  oakum, 
marine  lint,  or  iodoformized  gauze,  a  T-bandage 
applied,  patient  placed  in  bed  Avith  limbs  ex- 
tended, and  morphia  or  opium  freely  given  to  re- 
lieve all  irritation  and  to  produce  constipation  of 
the  bowels.  The  food  should  be  light,  and  not  of 
a  nature  likely  to  leave  a  residue.  In  ten  days  or 
two  weeks  make  use  of  a  mild  cathartic  in  con- 
junction with  a  copious  enema. 

Incision  with  Closure. — If  the  extent  of  the 
sinus  will  permit  it,  the  entire  track  may  be  re- 
moved and  the  resulting  wound  closed  by  catgut 
sutures,  carried  deep  enough  to  bring  the  walls  of 
the  wound  in  contact.  Two  sets  of  sutures  may 
be  employed  ;  one,  a  superficial  set,  which  shall 
bring  the  borders  of  the  mucous  membrane  to- 
gether, while  the  second  should  unite  the  deeper 
structures.  In  this  manner  union  by  first  inten- 
tion may  be  secured,  thus  shortening  the  period 
of  recovery  and  obviating  all  danger  of  fecal  incon- 
tinence dependent  upon  the  incomplete  closure, 
which  sometimes  occurs  when  the  cut  is  deep  and 
is  permitted  to  heal  from  the  bottom.  If,  how- 
ever, there  be  a  cavity  at  the  upper  end  of  the  si- 
QOfj  or  if  any  portion  of  the  track  be  not  dissected 
out,  the  recovery  by  rapid  healing  will  be  retarded 
if  not  entirely  prevented. 

,,.  '        _  .  .  ..,,  Fio.  630. — AlhnKham'B 

Ireatment  by  Ligaturing. — I  he  elastic  liga-  ligature-carrier. 


408  OPERATIVE  SURGERY. 

ture  is  the  only  one  worthy  of  consideration.  It  consists  of  a  rubber 
cord  about  one  tenth  of  an  inch  in  diameter.  This  is  carried  through 
the  sinus  into  the  gut  by  an  appropriate  instrument  (Fig.  630),  the 
inner  extremity  drawn  out  through  the  anus  and  tied,  after  any  integ- 
ument which  might  be  included  in  its  grasp  has  been  divided,  to  pre- 
vent the  pain  and  delay  incident  to  the  division  of  its  peculiar  struct- 
ure. A  strong  silk  thread  can  be  substituted  for  the  more  elaborate 
apparatus  shown  in  Fig.  630.  This,  after  being  passed  through  the 
sinus  and  attached  to  the  rubber  cord,  can  be  employed  to  carry  it 
into  position.  It  is  sometimes  difficult  to  tie  a  knot  in  the  rubber 
cord  securely.  Still,  this  can  be  accomplished  easily  by  tying  the  first 
half  of  the  knot  over  a  silk  ligature  placed  at  right  angles  to  the 
course  of  the  elastic  one,  and  then  tying  the  silk  ligature  firmly  around 
the  half-knot.  This  holds  the  elastic  cord  securely  while  the  knot  is 
completed.  The  elastic  ligature  will  cut  its  way  through  in  six  or 
eight  days. 

This  method  possesses  some  advantages  over  that  by  incision, 
among  which  may  be  noted  that,  in  simple  cases,  little  or  no  pain  is 
inflicted,  and  the  patient  'can  walk  out-doors  without  any  especial 
danger. 

Nervous  persons  will  often  submit  to  it  when  they  will  not  to  the 
knife.  There  is  no  bleeding,  which  is  of  advantage  when  the  larger 
vessels  may  be  implicated,  or  when  an  undue  tendency  to  hemorrhage 
exists.  It  is  the  best  method  in  phthisical  patients,  for  manifest 
reasons.  It  can  be  employed  in  all  cases  where  but  a  single  sinus 
exists  ;  if,  however,  a  second  be  present,  the  result  must  of  necessity 
be  unsatisfactory,  as  this  involves  a  repetition  of  the  operation  or  the 
use  of  the  knife. 

The  galvano-cautery  does  not  secure  better  results  than  incision, 
and  is  much  more  cumbersome  in  its  application ;  still,  it  is  useful 
when  dangerous  hemorrhage  is  apprehended. 

Surgical  Anatomy  of  the  Rectum. — The  length  of  the  rectum  is 
from  six  to  eight  inches,  the  latter  being  the  length  of  advanced  life. 
It  has  various  curves.  The  first,  an  inch  and  a  half  in  length,  extends 
from  the  anus  to  near  the  prostate,  and  is  directed  upward  and  for- 
ward, a  fact  which  should  be  remembered  in  the  introduction  of 
instruments.  The  second  portion  follows  the  curve  of  the  sacrum, 
and  is  about  three  inches  in  length  ;  the  greater  portion  of  this  is 
covered  by  peritoneum,  it  being  reflected  upon  it  at  a  point  about  two 
and  one  half  inches  above  the  anus  in  front,  and  about  five  inches 
behind,  when  the  bladder  and  rectum  are  empty;  if  filled,  the  dis- 
tance is  increased  about  an  inch.  The  anterior  surface  of  the  lower 
part  of  this  portion  is  intimately  associated  with  the  base  of  the  blad- 
der, vesiculas  seminales,  and  prostate  body  in  the  male.  In  the  female 
the  posterior  wall  of  the  vagina  is  in  front.     The  third  curve  extends 


OPERATIONS  OX  THE  ANUS  AND  RECTUM.         409 

from  the  middle  of  the  third  piece  of  the  sacrum  to  the  left  sacro- 
iliac synchondrosis.  This  portion  is  almost  entirely  surrounded  by 
serous  membrane.  The  vessels  having  surgical  associations  with  the 
rectum  are  the  superior,  middle,  and  inferior  hemorrhoidal  arteries. 
The  first  is  the  most  important ;  it  runs  between  the  rectum  and  the 
sacrum,  a  little  to  the  left  of  the  median  line,  to  within  about  four  or 
four  and  a  half  inches  of  the  anus.  Its  branches  run  parallel  with 
the  long  axis  of  the  bowel  down  to  the  anus,  and  can  be  best  avoided 
by  longitudinal  incisions. 

For  a  rectal  examination  the  patient  is  placed  in  one  of  the  many 
positions  previously  cited.  The  bowel  should  be  thoroughly  emptied 
and  cleansed  prior  to  the  attempt.  One  or  two  fingers,  or  even  the 
whole  hand,  may  be  introduced,  or  the  tube  may  be  inspected  through 
the  various  forms  of  specula. 

If  the  examination  is  made  with  the  index-finger,  it  should  be  wrell 
oiled  and  inserted  with  a  semi-rotary  motion,  allowing  the  remaining 
fingers  to  lie  in  the  median  line  between  the  buttocks.  In  this  man- 
ner, by  the  use  of  moderate  force,  the  lowrer  four  or  five  inches  of  the 
organ  maybe  examined.  The  introduction  of  the  middle  finger  along 
with  the  index-finger  will  somewhat  increase  the  range  of  examina- 
tion, especially  if  the  patient  be  requested  to  bear  down. 

The  introduction  of  the  whole  hand  must  be  done  with  great  cau- 
tion in  order  not  to  lacerate  the  bowel  or  the  peritoneum  enveloping  it. 
For  this  purpose  the  patient  is  placed  upon  the  back,  anaesthetized, 
bladder  emptied,  and  the  services  of  a  person  with  a  small  hand,  not 
exceeding  eight  inches  in  circumference,  are  enlisted.  The  hand 
should  be  well  oiled,  and  a  conical  form  given  to  it  by  applying  the 
thumb  to  the  palmar  surface  of  the  approximated  fingers.  The  tips 
of  the  fingers  are  then  inserted  by  a  semi-rotary  motion,  which  is 
slowly  continued  until  the  whole  hand  enters  the  bowel.  After  the 
entrance  of  the  hand,  the  fingers  are  to  be  moved  in  various  direc- 
tions to  ascertain  the  caliber  of  the  gut,  and,  at  the  same  time,  favor 
the  circulation  of  the  imprisoned  hand. 

If  the  hand  meets  a  narrowing  of  the  bowel  at  a  distance  of  three  or 
four  inches  above  the  anus,  but  little  force  should  be  used,  as  the  peri- 
touenm,  which  is  connected  with  the  gut  in  this  situation  and  is  the 
cause  of  the  narrowing,  may  be  ruptured.  If  the  hand  be  small,  it 
not  unfrequently  happens  that  the  sigmoid  flexure  may  be  passed,  the 
descending  colon  entered,  and  the  kidneys,  uterus,  and  great  vessels 
may  ),<■  examined  through  it.  It  is,  however,  extremely  fatiguing  to 
the  examiner  ;  still,  the  discomfort  experienced  should  not  lead  the 
surgeon  to  relax  in  the  least  the  degree  of  caution  necessary  to  the 
safety  of  the  patient. 

Prolapsus  Ani. — Prolapsus  ani  occurs  in  two  distinct  varieties  : 
first,  a3  a  partial  or  complete  prolapse  of  the  mucous  membrane  alone 


410 


OPERATIVE   SURGERY. 


(Fig.  631)  ;  second,  as  a  prolapsus  implicating  the  deeper  tissues,  often 
attended  by  invagination  (Fig.  632).     The  aims  in  the  operative  treat- 


Fig.  631. — Prolapsus  ani. 


Fig.  632. — Prolapse  with  invagination. 


ment  of  the  former  consist  in  producing  adhesions  of  the  mucous 
membrane  to  the  tissues  beneath  it,  and  a  narrowing  of  the  orifice  of 
the  anus  by  stimulating  the  function  of  the  sphincter.  The  adhe- 
sions may  be  established  by  clamping  and  destroying  isolated  portions 
of  the  mucous  membrane,  or  by  removing  similar  portions  of  it  by 
the  ligature  or  the  galvano-cautery.  If  piles  be  present,  they  should 
be  ligatured,  as  this  will  alone  often  effect  a  cure.  The  application 
of  Paquelin's  cautery,  longitudinally  or  at  isolated  points,  to  the  pro- 
lapsed part,  after  its  return,  is  an  excellent  method  of  procedure,  and 
this,  when  combined  with  rest  in  the  horizontal  position  and  the  pro- 
duction of  fluid  evacuations,  as  adjuvants  to  the  treatment,  will  usually 
effect  a  speedy  and  satisfactory  cure. 

Operation. — The  patient  must  be  anaesthetized,  placed  in  the  knee- 
elbow  position,  the  prolapse  reduced,  and  the  parts  exposed  by  the 
Sims'  speculum.  Then  four  or  five  longitudinal  stripes  about  three 
inches  in  length  are  made  with  the  point  of  a  cautery  at  a  dull-red 
heat,  at  equal  intervals  apart,  and  terminating  externally  at  the  border 
of  the  true  skin.  The  number,  size,  and  depth  of  the  eschars  made 
will  depend  on  the  age  of  the  patient  and  the  severity  of  the  case.  In 
the  infant,  two  or  three  a  line  or  two  in  width  may  be  sufficient.  The 
older  the  patient  and  the  severer  the  case,  the  deeper  should  be  the 
eschars.  The  possibility  of  reanimating  the  sphincter  is  somewhat 
uncertain,  yet  the  medical  expedients  directed  to  the  restoration  of 
paralyzed  muscles  may  be  employed  with  some  success.     The  anus 


OPERATIONS  OX  THE  ANUS  AND  RECTDM. 


411 


may  be  narrowed  by  removing  elliptical-sbaped  pieces  from  the  mu- 
cous membrane  and  uniting  their  raw  surfaces  ;  and  also,  by  linear 
eschars  made  in  a  manner  similar  to  that  for  prolapsus  aui. 

Expedients  of  this  kind,  while  they  frequently  fail  of  curing,  gen- 
erally give  marked  relief  to  the  patient. 

The  second  or  complete  variety  of  prolapse  exists  in  three  forms  : 
1.  In  which  the  external  surface  is  devoid  of  a  sulcus  ;  in  this,  the 
prolapse  follows  as  the  result  of  the  continuous  traction  exerted  by 
long-standing  prolapse  of  the  mucous  membrane.  Peritoneum  exists 
in  the  tumor,  and  sometimes  also  a  loop  of  intestine  (Fig.  633).  2. 
In  which  a  sulcus  exists  at  the 
base  of  the  tumor,  at  the  bot- 
tom of  which  the  lining  mem- 
brane of  the  gut  can  be  felt  as 
it  is  reflected  from  the  invagi- 
nated  protrusion.  3.  In  which 
the  finger,  when  introduced 
into  the  anus  beside  the  tu- 
mor, fails  to  detect  any  evi- 
dence of  the  reflection  of  the 
mucous  membrane  of  the  rec- 
tum upon  the  tumor,  because 
the  invagination  is  extensive, 
involving  the  colon,  caput  coli, 
and  sometimes  the  ileum  it- 
self. 

All  three  varieties  must 
first  be  reduced  ;  sometimes 
this  is  accomplished  with  great 
difficulty,  especially  when  an 
acute  case  is  complicated  with 
evidences  of  strangulation  of 
the  protruding  portion. 

Place  the  patient  in  the 
knee-elbow  position,  and  endeavor  carefully  to  return  the  part  first 
which  escaped  last,  and,  if  necessary,  the  external  sphincter  can  be 
divided.     If  this  fail,  renew  the  effort  by  reducing  the  part  first  that 

iped  first.  If  the  case  be  a  severe  one,  the  mucous  membrane  of 
the  protrusion  can  be  painted  with  a  solution  of  cocaine,  and  even  an 
anesthetic  may  be  given.  To  the  treatment  of  the  third  variety  of 
prolapse  must  be  added  the  copious  injection  into  the  bowel  of  fluids 
<»r  gases,  the  introduction  of  the  hand,  etc. 

The  after-treatment  of  the  first  two  forms  of  the  second  variety 
is  substantially  the  same  as  that  for  the  first  variety,  except  it  should 
be  more  rigorously  and  persistently  applied,  and  the  patient  be  con- 


FiG.  633. — Complete  prolapse,  with  peritoneum. 
R.  Rectum.  B.  Bladder.  S.  Sacrum.  P. 
Tubes.  U.  Uterus.  V.  Vagina.  CSP. 
Cavity  of  the  peritoneal  sac. 


412  OPERATIVE  SURGERY. 

fined  to  the  recumbent  position  and  be  required  to  use  a  bed-pan. 
It  is  not  advisable  in  any  of  the  forms  of  prolapse  to  resort  to  the 
direct  removal  of  the  protruding  portion  by  means  of  the  knife  or 
ligature  until  all  other  methods  have  been  faithfully  tried  and  have 
failed. 

In  the  third  form  of  the  second  variety  the  question  of  laparotomy 
must  be  considered  ;  and  the  answer  to  the  question  as  to  whether  it 
should  be  performed  or  not,  will  depend  largely  on  the  symptoms  and 
conditions  of  the  case.  Its  early  performance,  however,  improves  the 
prognosis  for  recovery. 

Cancer  of  the  Rectum. — Excision  of  the  rectum  and  colotomy  are 
the  only  operative  measures  of  radical  importance  employed  in  this 
disease. 

Eectotomy,  or  External  Proctotomy.  —  Place  the  patient  in  the 
lithotomy  position,  empty  the  bladder,  expose  the  posterior  wall  of 
the  rectum  by  a  Sims'  speculum,  and,  with  the  Paquelin  cautery,  or 
with  a  knife,  make  an  incision  through  the  diseased  mass  at  the  pos- 
terior aspect  of  the  gut,  about  four  inches  in  length,  carrying  it 
downward  through  the  sphincters.  The  ecraseur  may  be  employed, 
introducing  the  chain  by  means  of  a  trocar  passed  from  the  tip  of  the 
coccyx  upward  behind  the  mass,  thence  into  the  gut,  and  dividing  the 
included  structures  slowly.  Eectotomy  is  only  a  palliative  measure, 
enabling  the  bowel  to  discharge  its  contents  more  readily  and  with  less 
pain.  Iodoformized  dressings,  combined  with  frequent  cleansing, 
comprise  the  local  after-treatment. 

Excision  of  the  Rectum. — Excision  of  the  rectum,  either  as  a  cura- 
tive or  a  palliative  measure,  is,  at  the  present  time,  a  generally  accepted 
surgical  procedure.  It  can  be  stated  as  a  conservative  precept,  how- 
ever, that  if  the  upper  limit  of  the  growth  can  not  be  easily  reached 
with  the  index-finger,  its  removal  should  not  be  contemplated,  owing 
to  the  contiguity  of  the  peritoneum.  Still,  even  under  these  circum- 
stances, if  the  mucous  membrane  be  involved  alone,  the  diseased 
structure  can  be  stripped  off  without  entering  the  peritoneal  cavity. 
If  contiguous  viscera  be  involved,  or  the  pelvic  lymphatic  glands  be 
enlarged,  the  expediency  of  the  operation  is  decidedly  questionable. 
Prior  to  the  operation  the  entire  length  of  the  intestinal  tract  should 
be  thoroughly  evacuated,  and  the  rectum  cleansed  by  antiseptic  ene- 
mata.  A  large  antiseptic  sponge,  with  a  string  attached,  is  then 
pushed  up  the  bowel  beyond  the  disease,  to  prevent  soiling  the  opera- 
tion field.  The  bladder  is  emptied,  and  a  sound  carried  into  it  to 
guide  the  operator  in  making  the  anterior  dissections.  An  anassthetic 
is  administered  with  the  patient  in  the  dorsal  position,  after  which  the 
position  may  be  changed  to  conform  to  the  convenience  of  the  opera- 
tor. The  entire  operation  should  be  conducted  with  strict  antiseptic 
precautions. 


OPERATIONS  ON  THE  ANUS  AND   RECTUM.  413 

Volkmann's  Method. — This  surgeon  has  described  three  different 
operations,  intended  to  meet  as  many  different  phases  of  the  disease  : 

1.  For  Removal  of  a  Circumscribed  Groivth. — Dilate  the  anus, 
pull  down  the  diseased  portion,  and  remove  it  by  an  incision  so  di- 
rected that  when  closed  the  caliber  of  the  bowel  will  be  diminished  as 
little  as  possible.  If  the  sphincter  have  been  involved,  its  fibers  should 
be  united  after  the  removal  of  the  growth,  and  deep  drainage  provided. 
If  the  growth  be  above  the  sphincter,  after  uniting  the  borders  of 
the  wound,  deep  drainage  must  be  made  by  allowing  the  tube  to  pass 
through  or  beneath  the  sphincter. 

2.  For  Removal  of  a  Groivth  involving  the  Circumference  of  the 
Bowel,  but  not  the  Anus. — Divide  the  anus  forward  into  the  perineum 
and  backward  to  the  tip  of  the  coccyx,  the  latter  incision  extending 
to  the  lower  limit  of  the  disease.  The  morbid  growth  is  dissected 
out  by  means  of  the  knife,  scissors,  fingers,  etc.  ;  the  healthy  mucous 
membrane  above  is  carefully  stitched  to  that  below,  and  deep  drain- 
age is  provided  behind  and  in  front,  and  the  anteroposterior  prelimi- 
nary incisions  are  carefully  closed. 

3.  For  Removal  when  the  Disease  involves  the  Circumference  of 
the  Bowel,  and  Part  of  or  the  Entire  Anus. — Make  the  preliminary  in- 
cisions as  in  the  second  class,  and  carry  a  circular  incision  around  the 
anus,  outside  of  the  sphincter,  from  which  the  dissection  is  carried 
upward  parallel  with  the  gut  to  the  upper  limits  of  the  morbid  growth, 
which  is  drawn  down,  the  healthy  mucous  membrane  above  it  stitched 
to  the  cutaneous  border,  and  the  disease  removed.  Deep  drainage  is 
then  provided,  the  parts  are  carefully  united,  and  the  wound  tam- 
poned with  iodoform  gauze.  If,  in  case  the  structure  of  the  bowel  is 
to  be  cut  transversely,  as  when  the  morbid  growth  is  being  completely 
separated,  the  healthy  portion  be  transfixed  and  tied  by  several  catgut 
ligatures  before  the  final  separation,  all  danger  of  hemorrhage  from 
this  source  is  avoided. 

Lately,  Volkmann  has  recommended  the  entire  removal  of  the  exter- 
nal sphincter,  whether  it  be  diseased  or  not,  as  he  believes  the  growth 
i-  less  liable  to  return  than  when  it  is  left.  If  it  be  found  difficult  to 
draw  down  the  mucous  membrane  of  the  bowel  sufficiently  to  readily 
unite  it  to  the  external  cutaneous  opening,  it  should  be  permitted  to 
remain  above,  and  the  exposed  surfaces  below  it  sprinkled  with  iodo- 
form or  naphthaline,  and  packed  around  with  antiseptic  gauze.  A 
tube  of  suitable  size  to  discharge  flatus  and  even  fecal  matter  may  be 
then  passed  up  and  confined  in  position.  By  these  simple  expedients 
tin-  raw  -ni-faff-  may  be  kept  quite  clean. 

The  prostate,  and  even  the  base  of  the  bladder,  have  been  removed 
in  conjunction  with  the  diseased  rectal  tissue,  but  there  is  little,  if 
anything,  to  be  said  in  support  of  this  measure. 

Oripp'a  Method.  —  Make  the  posterior  incision  by  passing  a  curved 


414 


OPERATIVE   SURGERY. 


bistoury  into  the  rectum  and  bringing  its  point  out  at  the  tip  of  the 
coccyx,  cutting  all  the  intervening  tissue.  Separate  the  parts  suffi- 
ciently to  put  the  tissue  on  the  stretch,  and  make  lateral  incisions 
from  the  posterior  cut  around  to  the  median  line  in  front,  on  each 
side,  either  without  or  within  the  anus,  according  to  the  location  of 
the  disease.  These  cuts  should  reach  into  the  ischio-rectal  fossae,  and 
each  one  be  completed  in  its  turn.  The  dissection  is  carried  above 
the  point  of  the  disease  in  the  usual  manner,  the  bowel  drawn  down- 
ward, and  the  morbid  growth  removed  with  an  ecraseur. 

Maisonneuve's  Method. — A  circular  incision  is  made  around  the 
anus,  through  the  integument  and  subcutaneous  tissue,  and  a  long, 
strong  needle,  bearing  at  its  point  a  ligature  one  foot  in  length,  is 
passed  upward  through  the  external  incision  outside  the  bowel  into 
the  gut  above  the  growth.  The  loop  of  the  ligature  is  seized  at  the 
eye  of  the  needle  and  drawn  out  of  the  anus,  while  the  needle  retraces 
its  course,  thus  depositing  a  double  uncut  ligature,  one  end  hanging 
by  the  amis,  the  other  lying  in  the  primary  incision.  A  sufficient 
number  of  ligatures  are  thus  deposited,  at  equal  distances  from  each 
other,  to  include  the  entire  circumference  of  the  gut.  A  strong 
whipcord,  about  six  feet  in  length,  is  now  passed  through  the  loops 
hanging  from  the  anus,  leaving  an  interval  of  about  ten  inches  be- 
tween each  loop.  The  ligatures  are  then  drawn  outward  by  seizing 
the  extremities  in  the  external  cut,  thereby  drawing  the  whipcord 
through  the  openings  made  in  the  bowel  by  the  receding  ligatures. 
Each  loop  of  the  whipcord  is  allotted  in  turn  to  an  ecraseur,  and  the 
portion  of  the  rectum  included  by  it  is  cut  through. 

Results. — The  rate  of  mortality  following  this  operation  is  from 
twenty  to  twenty-five  per  cent.     The  operation  is  a  proper  one,  under 

favorable  conditions,  and  will  pro- 
long the  life  of  eighty  per  cent  of 
the  patients,  and  effect  a  cure  in  a 
small  proportion  of  them. 

Stricture  of  the  Rectum. — Ordi- 
narily a  stricture  of  the  rectum  is 
treated  upon  substantially  the  same 
principles  as  a  stricture  of  the  ure- 
thra :  the  repeated  use  of  rectal 
bougies  passed  in  the  direction  of 
its  curvatures  ;  nicking  its  edges 
with  a  probe-pointed  knife  ;  divul- 
sion,  elastic  distention,  rectotomy, 
and,  finally,  if  the  stricture  be  high 
up,  colotomy. 

Imperforate  Rectum  (Fig.  634). 
— This  form  of  occlusion  varies  in 


Fig.  634. — Imperforate  rectum. 


OPEPvATIONS   ON   THE   ANUS  AND   RECTUM. 


415 


thickness,  and  is  usually  situated  within  half  an  inch  of  the  anus, 

which  is  normal.     If  the  structure  be  thin,  it  will  be  influenced  by 

the    emotions    of    the 

child  and  depressed  by 

the  superimposed  fecal 

accumulations. 

Operation. — A  radi- 
ating incision,  with  its 
center  corresponding  to 
that  of  the  obstruction, 
can  be  made  through 
the  tissues,  the  contents 
of  the  gut  evacuated, 
the  flaps  trimmed  off, 
and  the  opening  main- 
tained by  the  occasional 
introduction  of  a  well- 
oiled  bougie.  Some- 
times the  occlusion  is 
so  thick  as  to  raise  the 
question  as  to  the  pres- 
ence or  absence  of  the 
gut  above.  The  sig- 
moid flexure  may  term- 
inate in  a  blind  point, 
while  the  rectum  below 
is  marked  by  an  impervious  cord  (Fig.  635).  An  attempt  should 
always  be  made  to  find  the  blind  extremity,  which  is  done  by  intro- 
ducing a  sound  into  the  bladder  and  carefully  seeking,  by  aid  of  the 
scissors  and  finger,  for  the  cul-de-sac  above.  In  doing  this,  the 
established  relation  which  the  rectum  bears  to  the  curve  of  the  sa- 
crum must  be  carefully  regarded,  and  the  fibrous  trace  of  the  rectum 
sought  after.  If  the  abdomen  of  the  patient  be  pressed  upon,  any 
existing  tumor  above  will  be  made  more  distinct  and  tense.  If  the 
cul-de-sac  be  found,  the  diagnosis  should  be  still  further  strength- 
ened by  exploring  it  by  means  of  a  hypodermic  syringe  or  a  small 
aspirating  needle  carried  into  its  posterior  aspect.  If  fecal  matter 
or  offensive  gases  be  detected,  the  blind  extremity  of  the  gut  is  drawn 
carefully  downward  toward  the  external  opening,  and  held  in  this 
position  by  forceps  or  by  a  loop  of  thread  passed  through  its  apex 
while  it  i-  opened  carefully,  the  incision  into  it  being  guided  by  the 
exploring  needle,  which  is  allowed  to  remain  for  that  purpose.  After 
the  contents  are  evacuated  and  the  parts  are  thoroughly  cleansed, 
a  sponge  with  a  string  attached  to  it  is  pushed  up  the  bowel  to 
prevent    any    further  escape  of  fecal  matter  while  the  extremity  of 


Fig.  635. — Rectum  ending  in  blind  pouch. 


416 


OPERATIVE  SURGERY. 


the  bowel  is  being  sewed  to  the  surface  below— if  practicable,  to  the 
cutaneous  border.  When  this  step  is  impracticable,  the  after-treat- 
ment should  be  the  same  as  that  following  excision  of  the  rectum. 
If  the  extremity  of  the  bowel  be  not  found,  colotomy  must  be  per- 
formed. Not  infrequently  the  rectum  communicates  with  the  bladder, 
and  even  the  glans  penis,  conditions  which  are  determined  by  the  fecal 
character  of  the  urine.  In  these  cases  the  bowel  should  be  sought 
for,  and,  when  found,  drawn  down  and  stitched  as  before,  and  the 
fecal  canal  kept  open  by  the  frequent  introduction  of  a  well- greased 
finger  or  a  suitable  bougie.  The  fistulous  openings  are  closed  with 
catgut,  suitable  drainage  provided,  and  the  contents  of  the  bladder 
evacuated  at  short  intervals,  to  prevent  its  distention  during  the  heal- 
ing process. 


CHAPTER  XVI. 

OPERATIONS   ON  THE  URINARY  BLADDER. 

The  cavity  of  the  bladder  may  be  explored  by  catheters,  sounds, 

and  searchers ;  its  outer  surface  by  rectal  and  abdominal  palpation. 

Catheters  can  be  practically  divided  into  the  soft  rubber,  silk,  gum- 


Fig.  636.— Mcrcier's    Fig.  637.—  Mercier's 
double      elbowed       elbowed  catheter, 
catheter. 


Fig.  638.— Self-re- 
taming  catheter. 


Fig.  639.— Holt's 
self-retaining 
catheter. 


elastic,  and  metal  varieties.     The  first  two  varieties  are  extremely  flex- 
ible, and  are  most  innocent  instruments  in  the  clumsiest  hands  (Figs. 


OPERATIONS   OX   THE   URINARY   BLADDER. 


417 


636,  G3T,  G38,  039,  642,  and  643).  It  is  sometimes  necessary  that  a  soft 
rubber  catheter  be  provided  with  a  guide  in  order  to  properly  direct  it 
as  well  as  to  overcome  any  slight  impediment  in  its  course  (Figs.  640 

and  641).  The  gum-elastic  and 
metal  instruments  are  too  fa- 
miliar to  all  to  require  a  de- 
scription, except  such  of  them 
as  have  been  especially  modified 
for  distinct  purposes. 

Introduction  of  a  Catheter  or 
Sound  into  the  Bladder. — Select 
an  instrument  of  a  suitable 
curve  and  size  ;  place  the  pa- 
tient on  the  back,  with  the 
shoulders  somewhat  raised,  and 
the  thighs  slightly  flexed  on  the 
abdomen,  and  rotated  outward 
to  relax  the  abdominal  muscles  ; 
warm  and  smear  the  instrument 


IV..  640.—  Fig.  641.— Otis'  Fig.    642.— OH- 

K<-  catheter-guide.  vary  gum  cath- 

cathet'-r-  eter. 
guide. 


Fig.  643. — Velvet-eye  catheter. 


with  oil  or  vaseline  ;  stand  on  the  left  side  of  the  patient ;  grasp  the 
penis  with  the  middle  and  ring  fingers  of  the  left  hand  and  raise  it 
vertically.  The  catheter  or  sound  is  then  taken  lightly  between  the 
thumb,  index,  and  middle  fingers  of  the  right  hand  and  introduced 
into  the  meatus,  held  open  by  the  left  index-finger  and  thumb.  The 
instrument  and  penis  should  now  be  carried  close  to  the  body  in  the 
27 


418 


OPERATIVE   SURGERY. 


line  of  the  groin.  The  penis  is  then  gently  drawn  over  the  instru- 
ment, which  at  the  same  time  is  carefully  pushed,  or  allowed  to  enter 
by  its  own  weight,  into  the  canal.  After  about  five  inches  of  the 
instrument  have  disappeared,  the  outer  extremity  should  be  carried 
toward  the  median  line  of  the  body  of  the  patient  and  elevated 
slowly  to  a  vertical  position,  when  its  weight  will  usually  cause 
the  advancing  end  to  pass  beneath  the  pubes  (Fig.  644),  after  which 
the  upper  extremity  is  depressed  between  the  thighs,  causing  the 
point  to  enter  the  bladder  (Fig.   645).     Not  infrequently  the  end 


Fig.  644. — Passing  catheter. 


will  hitch  upon  the  triangular  ligament  as  it  passes  beneath  the 
arch  of  the  pubes.  This  can  be  obviated  by  raising  the  point  of 
the  instrument  at  this  situation  by  the  finger  pressed  firmly  against 
the  median  line  of  the  perineum,  accompanied  by  upward  traction 
as  the  point  is  being  advanced  ;  in  a  word,  causing  the  instrument 
to  hug  the  roof  instead  of  the  floor  of  the  canal.  The  beginner  is 
apt  to  carry  the  handle  of  the  instrument  between  the  thighs  too 
soon,  causing  the  beak  to  be  reversed  in  front  of  the  pubes.     Un- 


OPERATIONS   ON   TDE   URINARY   BLADDER. 


419 


der  no  consideration  must  violence  be  employed  in  introducing  a 
catheter,  ars  non  vis  being  an  almost  traditional  axiom  in  this  con- 
nection. The  surgeon  should  always  follow  the  advancing  end  of  the 
instrument  with  the  mind's  eye,  aiming  to  keep  it  in  the  axis  of  the 
urethral  curve.     The  first  approach  of  the  instrument  to  the  perineal 


Fig.  645. — Catheter  entering  bladder. 


portion  of  the  urethra  not  infrequently  causes  a  contraction  of  the 
muscles  of  this  region,  which  interposes  an  effectual  temporary  obsta- 
cle to  its  advancement.  If,  however,  the  patient's  attention  be  en- 
gaged in  conversation  or  otherwise  diverted  from  the  procedure,  while 
at  the  same  time  the  end  of  the  instrument  is  pressed  continuously 
and  carefully  against  the  obstacle,  it  will  soon  give  way  and  enter  the 
bladder  without  further  trouble.  If  it  be  a  catheter,  the  flow  of  urine 
usually  announces  its  entrance  into  the  bladder.  However,  if  the  eye 
of  the  catheter  be  obstructed,  or  a  sound  be  introduced,  the  exact 
situation  of  the  instrument  may  be  determined  by  rotating  it  on  its 
long  axis  ;  when,  if  the  beak  be  in  the  viscus,  its  extremity  will 
describe  the  arc  of  a  circle  around  its  shaft  as  a  center  ;  if  not,  then 
the  shaft  will  describe  a  circle  around  its  beak.  If  the  bladder  be 
empty  or  contracted,  the  impinging  of  the  beak  upon  its  walls  may 
deceive  the  beginner  and  also  cause  the  patient  much  pain.  The  in- 
troduction of  the  index-finger  into  the  rectum  will  aid  in  guiding  the 
instrument  into  the  bladder,  and  determine  the  fact  of  its  entrance  as 
we\L  Hot  fomentations  to  the  abdomen,  together  with  an  anodyne 
and  a  ten-grain  dose  of  quinine,  should  be  employed  if  a  urethral 
chill  \)c  feared.  The  injection  into  the  urethra  of  a  weak  solution 
of  carbolic  acid  and  oil  after  the  passage  of  the  sound  is  thought  to 
sometimes  prevent  urethral  chills. 


420  OPERATIVE   SURGERY. 

Retention  of  Urine.— Retention  of  urine  depends  upon  some  ob- 
struction to  its  egress,  located  at  the  neck  of  the  bladder,  or  in  the 
course  of  the  urethra ;  also  upon  paralysis  of  the  muscular  coats  of 
the  bladder,  or  upon  both  combined. 

The  indications  are  met  by  overcoming  the  obstruction  or  restoring 
tone  to  the  bladder.  If  the  obstruction  be  due  to  stricture,  and  it  be 
permeable,  catheterization  will  effect  ready  relief.  It  is  important  to 
know,  however,  that  the  bladder  should  not  be  entirely  emptied  of  its 
contents,  but  that  only  a  sufficient  amount  of  urine  should  be  drawn 
to  afford  complete  relief  from  all  pain  and  tension.  If  it  be  completely 
emptied,  its  walls  will  collapse  from  want  of  support,  causing  conges- 
tion of  its  lining,  and,  in  all  probability,  the  catheter  will  be  required 
at  the  next  attempt  at  urination.  If  but  a  third  or  a  half  of  the  con- 
tents be  withdrawn,  the  bladder  will  probably  expel  its  contents 
properly  at  the  next  act  of  micturition.  If  it  be  impossible  to  intro- 
duce an  ordinary  catheter,  even  of  a  small  size,  recourse  must  then  be 
had  to  the  filiform  bougies  (Fig.  6&Q)  or  whalebone  guides  (Fig.  647). 


3ltf=3 


Fig.  649. — Filiform  bougies. 


The  latter  are  more  commonly  employed.  The  patient  is  placed  in 
the  dorsal  position,  an  anaesthetic  given,  unless  the  bladder  be  much 
distended — as  then  there  is  danger  of  its  rupturing  during  the  strug- 
gles of  the  patient.  If  anaesthesia  be  necessary  under  such  a  circum- 
stance, it  is  advisable  to  relieve  the  bladder  of  some  portion  of  the 
fluid  by  supra-pubic  aspiration.     If  one  be  not 

"~"~ v        entirely  familiar  with  the  use  of  the  whalebone 

guides  and  the  retention  catheter,  local  or  gen- 
- 'v.      eral  anaesthesia  is  not  advisable,  as  then  the  pa- 
tient's sensations  can  not  be  consulted,  and  great 
____ __________      harm  might  arise  from  their  use. 

T1     „.„    w  ".   ,  Introduction  of  Whalebone  Guides. — The  ure- 

IiG.  647. — Gouley's  . 

whalebone  guides.  thra  is  forcibly  filled  with  sweet-oil  by  means  oi 
a  syringe,  and  the  end  of  the  penis  grasped  to  re- 
tain it  as  long  as  possible,  leaving  sufficient  room  at  the  meatus 
for  the  introduction  of  a  whalebone  guide.  The  guide  is  carefully 
introduced,  and  if  its  point  becomes  engaged  in  a  lacuna,  it  is  with- 
drawn a  little  and  again  carried  onward  with  a  rotary  motion.  If  it 
enters  a  false  passage,  it  is  allowed  to  remain  there,  while  another 
guide  is  passed  by  its  side.  If  a  second  enters  the  false  passage,  it  is 
treated  in  a  similar  manner,  and  so  on  until  four  or  six,  or  even  more, 
are  contained  in  the  canal,  some  of  which  have  the  spiral  and  others 


OPERATIONS   ON   THE   URINARY   BLADDER. 


421 


the  straight  end  foremost.  Each  one  is  then 
taken  separately  and  pressed  onward  with  or 
without  the  spiral  twist,  always  remembering 
to  use  no  force,  else  the  small  points  may 
pierce  the  mucous  membrane  of  the  urethra, 
or  enter  and  perforate  Cowpers  ducts.  As 
soon  as  all  the  side  openings  are  closed  by  the 
extremities  of  the  guides,  one  guide  will  be 
found  to  have  entered  the  stricture,  and  with 
a  little  coaxing  will  pass  into  the  bladder, 
which  is  known  by  the  painless  ease  with 
which  it  can  be  moved  in  and  out.  The 
others  are  then  withdrawn,  and  the  end  of  the 
one  remaining  is  passed  through  the  eye  of  a 
tunneled  sound  (Fig.  648),  or,  what  is  better, 
the  tunneled  catheter  (Fig.  649).  This  guide 
serves  to  direct  the  passage  of  the  instrument 
into  the  bladder,  which  should  be  done  cau- 
tiously, as  the  guide  may  be  cut  by  the  eye  of 
the  instrument,  causing  it  to  double  and  lead 
the  end  of  the  catheter  astray.  The  instru- 
ment is  known  to  have  entered  the  bladder  if 
urine  flows  from  it,  or  if  its  innermost  ex- 
tremity can  be  turned  from  side  to  side.  After 
the  requisite  amount  of  urine  is  withdrawn, 
a  tunneled  sound  of  larger  size  may  be  passed 
in  a  similar  manner  as  the  catheter,  after 
which  the  guide  can  be  taken  out  and  an 
ordinary  steel  sound  of  small  size  carefully 
introduced  to  insure  a  channel  of  sufficient 
capacity  to  admit  the  ready  entrance  of  an 
instrument  thereafter. 

Aspiration  of  the  Bladder. — The  contents 
of  the  bladder  can  be  removed  by  aspiration 
by  introducing  the  aspirating  needle  into  it 
above  the  pubes,  at  the  point  indicated  for  the 

•if  a  trocar  (Fig.  657).  This,  however,  is  a  temporary  measure 
only.  The  same  can  be  said  of  tapping  per  rectum.  These  are 
important  expedients  to  enable  the  surgeon  to  gain  time  for  the 

performance     of 

1      '  S57^H^ 


Fig.  648. — Gouley's  tunneled 
sound. 


Fio.  649. — Gouley's  tunneled  eathcter  and  guide. 


external  perineal 
urethrotomy. 

Rupture  of 
the  Bladder. — 
Rupture    occurs 


422  OPERATIVE   SURGERY. 

most  frequently  on  the  posterior  surface,  involving  the  peritoneum, 
and  allowing  the  urine  to  escape  into  the  abdominal  cavity.  When 
the  rupture  occurs  anteriorly,  the  extravasated  urine  infiltrates  the 
perineum  and  the  anterior  walls  of  the  abdomen. 

Free  incisions  to  relieve  the  extravasation  and  the  performance  of 
cystotomy,  together  with  the  opening  of  the  abdomen  in  the  median 
line — laparotomy — to  remove  the  urine  contained  in  its  cavity,  are  the 
practical  operative  procedures. 

Cystotomy. — This  operation  consists  in  opening  into  the  bladder 
through  the  median  line  of  the  perineum,  as  in  the  median  operation 
for  stone.  Place  the  patient  on  the  back,  evacuate  the  rectum,  intro- 
duce a  grooved  staff  into  the  bladder,  and  with  a  sharp  knife  make  an 
incision  in  the  median  line  about  two  inches  in  length,  terminating 
about  half  an  inch  in  front  of  the  anus  ;  by  repeated  applications  of 
the  knife  the  staff  is  reached  and  the  membranous  urethra  opened 
backward  to  the  apex  of  the  prostate.  Introduce  a  small  probe  into 
the  bladder  by  way  of  the  groove  in  the  staff,  withdraw  the  staff  cau- 
tiously, introduce  the  index-finger  into  the  bladder  along  the  probe  as 
a  guide,  and  distend  the  neck  of  the  bladder  sufficiently  to  cause  the 
urine  to  escape  as  fast  as  it  flows  into  the  bladder.  The  prostatic 
structure  must  be  well  dilated,  else  it  will  soon  return  to  its  normal 
condition  and  require  a  repetition  of  the  dilating  process.  The  pros- 
tate may  be  incised  on  either  one  or  both  sides,  as  in  lateral  and  bi- 
lateral lithotomy  ;  it  is  necessary  to  do  so  to  maintain  the  patency  of  the 
opening  for  any  length  of  time.  Cystotomy  is  now  quite  frequently 
performed  as  an  ultimate  expedient  in  obstinate  cystitis  in  both  sexes. 
In  the  female  the  incision  is  made  into  the  bladder  through  the 
vagina. 

Prognosis. — The  operation  implies  about  the  same  danger  to  life 
as  the  median  operation  for  stone  in  the  bladder. 

Digital  Exploration  of  the  Bladder. — This  procedure  is  resorted 
to  for  the  purpose  of  detecting  encysted  calculi,  polypoid  and  other 
morbid  growths,  and  to  settle  many  vexatious  questions  relative  to 
the  bladder  cavity.  It  must  of  necessity  be  preceded  by  a  prelimi- 
nary cystotomy. 

In  order  to  properly  accomplish  the  purposes  of  an  exploration, 
anaesthesia  to  complete  muscular  relaxation  is  essential ;  the  finger-tip 
must  enter  the  bladder,  which  should  be  empty  and  be  depressed  by 
supra-pubic  pressure. 

Instruments  such  as  forceps,  scoops,  curettes,  etc.,  of  various  sizes 
and  patterns,  can  then  be  introduced  into  the  organ  to  remove  the 
offending  agent. 

After  the  operation  the  bladder  is  washed  out,  and  a  large-sized  cath- 
eter is  introduced  through  its  neck  to  drain  it  of  its  contents 'for  four 
or  five  days,  and  the  occurrence  of  hemorrhage  carefully  watched  for. 


OPERATIONS   ON   THE   URINARY   BLADDER. 


423 


Prognosis. — The  digital  exploration  of  the  bladder  of  itself  im- 
plies no  especial  danger  to  the  patient  if  the  kidneys  he  sound,  but 
cystotomy  and  removal  of  morbid  growths,  especially  of  a  villous  char- 
acter, by  crushing  or  curetting,  may,  in  the  latter,  give  rise  to  severe 
if  not  fatal  hemorrhage,  or  cause  death  from  blood-poisoning.  This 
operation  is  reported  to  have  been  performed  frequently,  but  the  re- 
sults are  not  sufficiently  definite  to  enable  one  to  estimate  a  percent- 
age, although  they  are  such  as  to  establish  the  entire  justice  of  the 
measure  in  severe  cases. 

Extroversion  of  the  Bladder. — In  extroversion  of  the  bladder  the 
anterior  wall  of  the  bladder  and  abdominal  parietes  are  absent,  while 
the  posterior  and  inferior  portion  of  the  bladder  protrudes  through 
the  opening  in  the  abdominal  wall  on  account  of  the  pressure  of  the 
viscera  behind  it.  Various  measures  have  been  attempted  to  establish 
a  more  feasible  channel  for  the  escape  of  urine,  none  of  which,  how- 
ever, have  afforded  any  practical  benefit.  Mr.  Simon  made  an  at- 
tempt to  connect  the  ureters  with  the  rectum,  but  with  indifferent 
success.  Floyd  and 
Johnson  attempted 
to  establish  a  fistu- 
lous communication 
between  the  bladder 
and  rectum  by 
means  of  setons, 
but  the  patient  died 
shortly  after  from 
peritonitis.  The 
methods  by  auto- 
plasty  are  the  most 
rational,  and  have 
in  many  instances 
afforded  substantial 
relief. 

Dr.  F.  F.  Mau- 
ry's Operation.  — 
Make  a  curvilinear  incision,  with  the  convexity  upward,  on  each  side, 
extending  from  the  outer  third  of  Poupart's  ligament  downward  and 
inward  below  the  scrotum  to  the  middle  of  the  perineum,  at  which 
point  they  become  joined  (Fig.  650).  This  flap,  1,  is  dissected  upward 
the  scrotum  to  the  root  of  the  penis,  which  is  slipped  through  a 
valve-like    incision    made  at  its  base,  thus   permitting  the  urine  to 

ipe  without  coming  in  contact  with  the  raw  surfaces.  A  second 
or  abdominal  flap  if  now  raised  transversely  across  the  abdomen,  ex- 
tending upward  from  below  the  umbilicus.  The  lower  flap,  1,  is  then 
turned  upward  to  bring  its  cutaneous  surface  in  contact  with  the  niu- 


Fig.  650. — Maury's  operation. 


424 


OPERATIVE   SURGERY. 


Fig.  651. — Bijrelow's  method. 


cous  surface  of  the  bladder  (Fig.  651,  2),  and  the  cuticle  is  removed 
from  all  portions  of  it  that  are  to  be  placed  in  contact  with  freshened 

surfaces.  The  edges 
of  the  lower  flap  are 
then  beveled  and  car- 
ried under  the  upper 
flap,  to  which  they  are 
united  by  catgut  su- 
tures. This  method 
offers  the  best  results 
in  operations  upon 
males.  Bigelow  dis- 
sected off  the  mucous 
membrane  of  the  ex- 
posed bladder  down  to 
a  line  with  the  ure- 
ters, constructed  lat- 
eral flaps  from  each 
inguinal  region  (Fig. 
651,  a,  b),  united  them 
in  the  median  line  and 
above  (Fig.  652),  and  thereby  secured  a  perfect  result. 

Wood's  Method  (Fig.  653). — This  is  best  adapted  to  female  subjects, 
and  consists  in  mak- 
ing a  central  or  um- 
bilical flap,  a,  and 
turning  it  down- 
ward over  the  blad- 
der, after  which  a 
flap  is  made  from 
each  groin,  b,  c,  and 
carried  inward  over 
the  everted  central 
one  and  united  in 
the  median  line  to 
the  other  (Fig.  654). 
This  arrangement 
brings  the  integu- 
mentary surface  of 
the  central  flap  in  contact  with  the  mucous  surface  of  the  bladder, 
and  the  raw  surfaces  of  the  central  and  lateral  flaps  are  apposed  ;  the 
uncovered  raw  surface  above  being  allowed  to  heal  by  granulation. 

Dr.  Pancoast  raised  two  flaps,  one  from  each  inguinal  region, 
joined  them  together  in  the  median  line,  and  allowed  the  raw  external 
surface  to  cicatrize. 


:* 


Fig.  652. — Bigelow's  flaps  united. 


OPERATIONS   OX  THE   URIXARY   BLADDER. 


425 


Fig.  653.— Wood's  method. 


Fig.  054. — Wood's  method. 
in  position. 


Flaps 


Ayres  covered  the  opening  by  turning  down  an  umbilical  flap  with 
its  raw  surface  uppermost ;  this  surface,  together  with  that  from  which 
it  was  taken,  was  covered  by  two  broad  flaps  dissected 
from  the  abdomen  at  both  sides,  of  sufficient  width 
to  fill  the  gap  when  joined  together  in  the  median 
line. 

Results. — Some  fifty-five  cases  have  been  oper- 
ated upon  by  one  method  or  auother,  with  the  sat- 
isfactory results  of  forty-three  successful  cases.  Four 
were  failures,  and  eight  fatal. 

Puncturing  the  Bladder  (Fig.  657). — Puncturing 
the  bladder  is  done  to  relieve  the  organ  from  over- 
distention.  It  can  be  done  above  or  below  the 
pubes,  and  through  the  rectum. 

It  may  be  performed  with  the  ordinary  curved 
trocar  (Fig.  655),  or  with  the  aspirator,  the  latter  be- 
ing the  safer  and  more  satisfactory. 

Above  the  Pubes  (Fig.  657). — Place  the  patient 


Fio.  655. — Rectum  trocar. 


Fig.  656.— Buck's 
rectum  trocar. 


426 


OPERATIVE   SURGERY. 


on  the  back ;  outline  the  distended  bladder  by  percussion  ;  explore 
the  tumor  with  a  hypodermic  needle  if  a  doubt  exists  as  to  its  nature. 


Fig.  657. — Puncturing  the  bladder. 

Select  a  small  straight  or  curved  trocar,  the  latter  being  the  better ; 
make  the  skin  tense  about  an  inch  above  the  pubis,  and  push  the  tro- 
car through  the  median  line  with  its  convexity  upward.  An  initia- 
tory incision  through  the  skin  is  often  made  with  a  sharp  knife  which 
permits  the  easier  entrance  of  the  trocar.  An  injection  of  cocaine 
may  relieve  the  patient  of  the  pain  caused  by  the  introduction  of  the 
trocar. 

Under  the  Pules. — If  the  bladder  be  small  and  shrunken  behind 
the  pubes,  or  the  prostate  be  too  large  to  admit  of  the  rectal  puncture, 
the  penis  can  be  pulled  downward,  and  a  small  curved  trocar,  with  the 
concavity  upward,  passed  just  beneath  the  arch  of  the  pubis  into  the 
viscus. 

Through  the  Rectum  (Fig.  657). — Place  the  patient  in  the  lithoto- 
my position ;  introduce  the  left  index-finger  into  the  rectum  ;  locate 
the  vesiculae  seminales  and  base  of  the  prostate  ;  place  the  end  of  the 
finger  between  the  former,  allowing  it  to  rest  upon  the  base  of  the 
prostate  ;  along  the  palmar  surface  of  the  finger,  a  curved  trocar  (Figs. 
655  and  656)  is.  then  carried  just  above  the  base  of  the  prostate,  and 


OPERATIONS   OX   THE   URINARY   BLADDER. 


427 


pushed  into  the  bladder ;  the  canula  may  be  tied  in  position,  or  a  soft 
catheter  substituted  therefor,  by  passing  it  through  the  canula. 

The  almost  universal  practice  of  using  some  form  of  aspirator,  and 
the  superiority  of  this  instrument  over  the  trocar,  are  fast  consigning 
the  latter  to  an  honorable  remembrance  only. 

STONE    IN"   THE   BLADDER. 

This  morbid  condition  is  quite  common,  and  usually  is  accom- 
panied by  well-marked  and  characteristic  symptoms.  Sometimes, 
however,  calculi  of  inordinate  size,  and  with  unusual  asperities,  are 
attended  by  only  trifling  man- 
ifestations. When  it  is  sus- 
pected that  a  stone  may  be  in 
the  bladder,  the  proof  of  its 
presence  is  sought  by  aid  of  a 
searcher.  There  are  various 
patterns  of  this  instrument 
(Figs.  658,  659,  and  660).  The 
one  devised  by  Thompson  is 
most  commonly  employed.  It 
can  be  used  for  the  double 
purpose  of  regulating  the 
amount  of  water  in  the  blad- 
der, by  injection  or  by  out- 
flow, thereby  better  accommo- 
dating the  bladder-walls  to  the 
remaining  function  of  this  in- 
strument— sounding  for  stone. 

Sounding.  —  The  time  se- 
lected should  be  when  the  pa- 
tient is  suffering  the  least  from 
the  bladder  difficulty.  If  the 
patient  be  a  child,  an  anaes- 
thetic should  be  given  ;  if  an 
adult,  only  when  he  is  ex- 
tremely restless  from  the  pain. 
Two  or  three  ounces  of  a  two- 
per-cent  solution  of  cocaine 
have  been  employed  success- 
fully in  the  bladder  to  relieve 
tin;  pain  and  irritation  of 
sounding  and  even  of  crash- 
ing. The  urine  of  one  or  two  hours'  secretion  should  be  allowed  to 
colled  in  the  bladder,  or  its  equivalent,  four  or  five  ounces  of  warm 
water,  should  be  injected  before  attempting  the  sounding. 


Fig.  658.—  Fir,.  659.— Lit- 
TJiompson's  tie's  searcher. 
searcher. 


Fig.  660.— Gou- 
ley's  searcher. 


428  OPERATIVE   SURGERY. 

Place  the  patient  on  the  back  with  the  hips  raised,  the  operator 
standing  upon  the  right  side.  Introduce  the  searcher  in  substantially 
the  same  manner  as  that  employed  to  introduce  a  lithotrite  (page  429); 
then  push  it  carefully  to  the  posterior  wall  of  the  bladder,  with  the 
beak  upward  ;  withdraw  it  slightly  to  give  easy  play  to  the  end,  and 
then  carefully  turn  the  beak  from  side  to  side,  until  the  lateral  walls 
of  the  bladder  are  touched  by  it.  This  is  done  by  rotating  the  instru- 
ment on  its  long  axis  between  the  thumb  and  finger.  In  this  manner 
the  whole  inner  surface  of  the  bladder  is  examined,  the  instrument 
being  withdrawn  each  time  a  sufficient  distance  to  accomplish  this 
object  thoroughly.  As  soon  as  the  beak  comes  in  contact  with  the 
neck  of  the  bladder  it  can  be  withdrawn.  If  the  prostate  be  enlarged, 
the  handle  should  be  depressed,  and  the  beak  turned  toward  the  floor 
of  the  bladder  and  rotated  from  side  to  side  while  it  is  being  gradually 
withdrawn.  This  manoeuvre  will  be  quite  sure  to  detect  the  stone  if 
it  be  lodged  behind  that  body. 

If  a  stone  be  not  detected,  it  is  better  to  make  a  second  and  even 
a  third  examination  before  positively  asserting  that  none  is  present. 
Five  or  ten  minutes  is  quite  sufficient  time  to  employ  at  one  sitting. 
If  the  presence  of  stone  be  detected,  the  number,  size,  and  the  proba- 
ble consistency  should  be  determined.  After  the  searching  is  com- 
pleted, apply  warmth  to  the  hypogastrium,  give  an  anodyne  along  with 
ten  grains  of  quinine,  and  keep  the  patient  quiet. 

The  ability  to  detect  the  "click"  from  small  fragments  by  aid  of 
the  searcher  is  greatly  enhanced  by  the  attachment  of  the  so-called 
"  lithophone."  This  attachment  can  be  extemporized  by  taking  a  piece 
of  rubber  tubing,  twenty-five  or  thirty  inches  in  length  with  an  eighth- 
inch  caliber ;  double  one  end  upon  itself  and  place  it  against  the 
handle  of  the  searcher,  allowing  also  the  tubing  continuous  with  it  to 
lie  along  the  handle,  or  push  it  into  the  open  end  of  the  handle  of  the 
searcher.  The  other  extremity  is  then  placed  in  the  ear  directly,  or 
connected  to  it  by  the  medium  of  an  otoscope.  The  ability  to  detect 
fragments  of  an  almost  infinitesimal  size  is  said  to  be  thus  attained. 
The  washing  process  of  litholapaxy  may  also  cause  the  "click." 

Litliotrity,  litholapaxy,  and  lithotomy  are  the  only  practical  meth- 
ods of  relief  in  the  male. 

Lithotrity  is  the  reducing  of  stone  to  fragments  so  minute  as  to 
allow  of  their  easy  escape  with  the  urine  through  the  urethra. 

The  instruments  used  to  effect  the  reduction  are  called  lithotrites, 
of  which  there  are  several  varieties  (Figs.  661,  664,  and  667).  The 
ones  devised  by  the  ingenuity  of  Thompson,  Bigelow,  and  Keyes 
are  most  frequently  used.  For  this  operation  the  patient  should  be 
in  a  good  condition,  and  the  urethra  of  suitable  size  to  admit  the 
lithotrites ;  he  is  required  to  hold  the  urine  for  an  hour  or  two,  and 
is  then  placed  upon  the  back  with  the  pelvis  elevated ;  the  older  the 


OPERATIONS   ON   THE   URINARY   BLADDER. 


420 


patient,  the  greater  the  elevation  should  he.  An  anaesthetic  may  be 
given,  and  should  be  administered  if  it  be  the  intention  to  triturate 
the  entire  mass  at  one  sitting ;  or,  if  the  patient  be  irritable,  or  the 
bladder  over-sensitive. 

Introduction  of  the  Lithotrite.— The  operator  having  chosen  and 
well  oiled  a  suitable  instrument,  stands  upon 
the  right  side  of  the  patient,  taking  the  penis 
in  the  left  hand,  inserts  the  beak  and  draws 
the  member  upward  upon  the  instrument, 
which  is  tightly  grasped  by  the  right.  The 
handle  is  then  slowly  raised  until  the  shaft  be- 
comes vertical,  when  it  is  transferred  to  the 
left  hand,  and  the  fingers  of  the  right  are  placed 
on  the  perineum  to  follow  the  angle  of  the 
beak  as  it  advances.  The  weight  of  the  in- 
strument will  cause  it  to  sink  low  enough  to 
permit  the  beak  to  engage  the  opening  of  the 
triangular  ligament,  through  which  the  urethra 
passes.    A  little  careful  manipulation,  aided  by 


Fig.  GG2. — Fenestrated  jaws. 


Fir;.  001.—  Thompson's 

lithotrite. 


Fi<;.  003. — Non-fenestrated  jaws. 


the  right  hand  on  the  perineum,  will  cause  it  to  enter  this  portion 
of  the  canal,  when  the  handle  of  the  instrument  should  be  taken  by 
the  right  hand,  and  allowed  to  fall  slowly  of  its  own  weight  between 
the  thighs.  If  the  instrument  be  now  slightly  pressed  upward,  its 
upper  extremity  will  be  found  to  be  disengaged,  and  can  be  easily  ro- 


430  OPERATIVE   SURGERY. 

tated  upon  its  long  axis.  If  the  prostate  be  enlarged,  it  increases  the 
length  of  the  deepest  portion  of  the  urethra,  and  interposes  an  ob- 
stacle to  its  progress.  The.  handle  should  not,  therefore,  be  depressed 
so  rapidly  during  the  latter  stage,  and  the  instrument  must  be  pushed 
farther  upward.  Under  no  consideration  should  any  undue  force  be 
used.  The  weight  of  the  handle  is  of  itself  sufficient,  unless  under 
proper  control,  to  cause  laceration  of  the  soft  urethral  tissues. 

The  instrument  is  pressed  upward  in  the  line  of  its  entrance  until 
it  reaches  the  posterior  wall  of  the  bladder,  unless  its  course  be  sooner 
interrupted  by  the  stone,  when  the  beak  is  turned  from  the  stone  and 
the  male  blade  withdrawn  ;  then  the  separated  blades  are  turned 
toward  the  stone,  which  is  seized  and  fixed.  The  beak  is  now  turned 
upward — care  being  taken  to  observe  that  the  mucous  lining  of  the 
bladder  is  not  caught — and  the  fragment  crushed.  The  blades  are 
again  separated  and  turned  sidewise  to  catch  the  resulting  fragments, 
which  manoeuvre  is  continued  until  the  sitting  is  completed. 

During  the  crushing,  the  female  blade  must  be  held  firmly  and 
remain  entirely  passive,  and  the  blades  should  only  be  separated  suffi- 
ciently to  admit  the  stone  between  them.  If  the  beak  be  not  turned 
away  from  the  stone  before  it  is  opened,  the  stone  may  be  displaced 
by  the  separation  of  the  blades.  While  it  is  true  that,  in  a  large  ma- 
jority of  cases,  the  plan  of  action  just  described  will  suffice,  still,  in 
those  where  the  prostate  is  enlarged,  or  an  excavation  exists  at  the 
base  of  the  bladder  from  another  cause,  it  may  become  necessary  to 
reverse  the  beak  of  the  instrument,  causing  it  to  look  toward  the  rec- 
tum. To  do  this  properly,  the  handle  of  the  instrument  is  depressed 
until  the  beak  is  elevated  sufficiently  to  allow  of  its  revolution  with- 
out impinging  upon  the  walls  of  the  bladder.  If  the  simple  revers- 
ing of  the  instrument  does  not  bring  it  in  contact  with  the  stone,  the 
beak  should  then  be  turned  in  various  directions  with  care.  Another 
manoeuvre,  which  in  the  case  of  small  stones  located  behind  the  pros- 
tate will  often  prove  successful,  consists  in  drawing  the  reversed  beak 
outward  until  it  nearly  touches  the  prostate,  and  then  separating  the 
blades  by  pressing  the  female  blade  backward  until  it  strikes  against 
the  posterior  wall  of  the  bladder,  the  male  blade  being  held  firmly  in 
position ;  raise  the  handle  until  the  female  blade  rests  lightly  upon 
the  floor  of  the  bladder,  then  draw  it  forward  to  join  the  male  blade, 
lightly  touching  the  floor  in  its  course.  If  a  stone  lies  in  the  line,  it 
will  be  touched,  and,  moreover,  the  mucous  membrane  will  not  be 
pinched.  It  is  better  that  the  blades  be  smooth  in  these  reversed 
movements. 

During  this  antero-posterior  manipulation  the  neck  of  the  bladder 
should  be  carefully  preserved  from  any  unnecessary  contact  with  the 
instrument.  When  the  sitting  is  completed  the  blades  must  be 
screwed  firmly  together,  that  the  instrument  may  be  withdrawn  with- 


OPERATIONS   ON   THE   URINARY   BLADDER. 


431 


out  iniurv  to  the  urethra.  Each  sitting,  if  without  anaesthesia,  should 
not  exceed  five  or  ten  minutes  ;  with  it,  a  sitting  can  be  prolonged 
uni  a  ordinary  calculus  is  reduced  to  fragments.  The  intend,  of 
the  crushing  will  depend  upon  the  size  of  the  stone  its  hardness  and 
more  frequently  the  effect  of  the  crushing  upon  the  patient  Inas- 
much as  the  conditions  differ  greatly,  it  is  impossible  to  lay  down 


Fig.  665. — Bigelow's  non-fenestratcd  blades. 


Fig.  666.— Bigelow's  fenestrated  blades. 


Fie.  664.— Blgelow'B 
Uthol 


Flflft  667,  668. — Keycs'  modified  blades. 


432 


OPERATIVE   SURGERY. 


any  stereotyped  rules. 


Fig.  669. — Thompson's  washer, 


The  surgeon  should  not  repeat  the  operation 
until  the  subsidence  of  the  irrita- 
tion produced  by  the  previous  at- 
tempts. Villous  growths  of  the 
bladder,  and  deformities  which  in- 
terpose a  mechanical  obstruction, 
are  the  principal  contraindications 
to  lithotrity.  After  the  completion 
of  the  sitting  the  patient  is  given 
an  anodyne,  and  hot  fomentations 
are  applied  to  the  abdomen,  and  he 
is  caused  to  remain  in  the  recum- 
bent posture  for  twenty-four  hours 
subsequent  to  the  operation,  even 
to  the  extent  of  lying  on  his  side 
during  micturition. 

Results. — The  rate  of  mortality 
is  about  eleven  per  cent. 


Rapid  Lithotrity,  or  Litlwlapaxy. — The  crushing  and  washing 
out  of  a  stone  at  a  single  sitting  has  supplanted  the  ordinary  lithot- 
rity. 


Fig.  670. — Bigelow's  washer. 

The  instruments  usually  employed  in  this  procedure  are  the  litho- 
trites  of  Thompson  or  Bigelow,  as  shown  in  Figs.  661  and  664,  the 
latter  being  in  common  use.  The  blades  of  lithotrites  differ  in  their 
grinding  surfaces  from  a  simple  roughening  to  a  well-marked  denticu- 


OPERATIONS   OX   THE   URINARY   BLADDER. 


433 


lation.     The  blades  of  Bigelow's  instruments  present  appearances  pe- 
culiar to  themselves  (Figs.  665  and  666).     The  instrument  used  by 


Fig.  672. — Otis'  washer,  inverted. 

Dr.  Keyes  is  of  a  stronger  pattern  than  is  usually  employed,  and  is 
provided  with  a  large  wheel  at  the  end,  that  a  greater  force  may  be 
quickly  applied.  The  blades  are 
trated  (Figs.  667,  668),  and 
are  so  constructed  that  they  can  not 
clog.  The  operator  should  possess 
litbotrites  of  two  or  three  sizes  and 
of  different  patterns,  to  enable  him 
to  comply  with  the  demands  of  in- 
dividual cases,  as  modified  by  the 
hardness  and  size  of  the  stone,  size 
of  the  urethra,  etc.  For  crushing 
large  and  hard  stones,  a  fenestrated 
blade  should  be  employed.  If  the 
itone  be  .-mall  and  friable,  the  blades 
may  be  roughened  only,  with  the  Fig.  673.— Bigelow's  evacuating  catheter. 
28 


434 


OPERATIVE   SURGERY. 


male  blade  much  the  smaller.     A  non-f enestrated  or  "  scoop  "  litho- 
trite  can  be  used  to  crush  the  smaller  fragments.     The  larger  and 

harder  the  concre- 
tion, the  stronger 
should  be  the  in- 
strument employed. 
In  addition  to  the  in- 
struments for  crush- 
ing, the  operator 
must  be  provided 
with  an  evacuator 
or  washer.  The 
Thompson  washer  is 
admirable  (Fig. 
669),  and  the  latest 
pattern  by  Bigelow 
leaves  but  little  to 
be  desired  in  this 
respect  (Fig.  670). 
Otis'  washer  is  sim- 
ple, cheap,  and  effi- 
cient (Figs.  671, 
672). 

The  evacuating- 
tubes  of  Bigelow 
(Fig.  673),  or  their 
modifications,  com- 
plete the  outfit.  The 
spiral-tipped  tube 
ofWarren(Fig.674) 
and  the  straight, 
open-ended  one  of 
Keyes  (Fig.  675), 
are  thought  to  fa- 


Fig.  674.— Warren's  Fig.  675.— Keyes'  Fig.  676.— Keyes 
spiral-tipped  evac-  straight  tube  and  curved  tube  and 
uating  catheter.  guide.  guide. 


cilitate  the  discharge  of  the  detritus,  while  in  the  latter  instance  es- 
pecially the  lining  membrane  of  the  urethra  is  not  exposed  to  injury 
from  a  fragment  lodged  in  the  eye  of  the  instrument  during  its  with- 
drawal from  the  bladder.  The  size  of  the  tube  commonly  employed 
varies  from  16  to  18,  English  scale. 

The  contraindications  to  the  operation  are  of  a  limited  number. 

It  is  not  admissible,  if  the  bladder  be  sacculated  and  affected  by 
cystitis,  or  if  it  be  ulcerated,  or  intolerant  of  the  presence  of  instru- 
ments. Eepeated  and  severe  chills  following  the  introduction  of  in- 
struments into  the  urethra  and  bladder  contraindicate  the  operation. 
If  the  organ  contain  morbid  growths,  or,  if  the  patient  be  feeble,  es- 


OPERATIONS   ON   THE   URINARY   BLADDER.  435 

pecially  if  the  stone  be  large  and  hard,  crushing  should  not  be  at 
tempted. 

The  preparatory  treatment  consists  in  alleviating  all  symptoms  de- 
pendent upon  the  existence  of  the  stone,  and  in  preparing  the  urethra 
for  receiving  the  instruments  by  increasing  its  size  if  necessary,  and 
subduing  any  undue  sensibility  of  it. 

Operation. — An  assistant,  besides  the  one  to  administer  the  ether, 
must  be  present  to  empty  the  washer  and  adjust  it.  The  bladder 
should  contain  four  or  five  ounces  of  fluid,  which  condition  is  best 
obtained  by  causing  the  patient  to  retain  the  urine  for  two  or 
three  hours  prior  to  the  operation ;  or,  if  it  be  empty,  a  similar 
amount  of  tepid  carbolized  water  must  be  injected.  If  the  contents 
of  the  bladder  be  offensive,  empty  it  and  wash  it  out  with  a  tepid 
solution  of  borax,  a  drachm  to  the  pint,  before  beginning  the  opera- 
tion. 

The  patient  is  placed  on  the  back,  complete  anassthesia  secured  to 
insure  perfect  quiet,  pelvis  elevated,  thighs  slightly  flexed  and  rotated 
outward. 

The  method  of  introduction  of  the  lithotrite,  and  the  process  of 
catching  and  crushing  the  stone,  are  similar  in  this  operation  to  the 
ordinary  method,  except  that  the  crushing  process  is  interrupted  by 
the  introduction  of  the  evacuating  catheter  as  soon  as  the  stone  is 
well  broken.  This  may  be  within  five  or  ten  minutes  after  the  intro- 
duction of  the  lithotrite,  depending,  of  course,  upon  the  success  at- 
tending the  efforts  of  the  operator.  A  well-oiled  evacuating  catheter 
is  then  passed  down  to  the  prostatic  urethra,  and  the  washer  is  at- 
tached while  it  is  in  this  situation  to  avoid  the  entrance  of  air  into 
the  bladder.  The  air  in  the  catheter  while  it  is  thus  located  will,  if 
water  be  forced  gently  into  it,  pass  upward  through  the  water  in  the 
washer  and  remain  in  the  air-trap  above,  after  which  the  evacuating- 
tube  is  carried  on  into  the  bladder.  If,  now,  the  elastic,  half-filled 
bulb  be  alternately  compressed  and  expanded,  the  changing  current 
thus  produced  will  wash  the  fragments  from  the  bladder,  and  their 
weight  will  precipitate  them  into  the  glass  receiver  beneath.  If  all 
the  fragments  be  not  removed — which  can  be  ascertained  by  the  intro- 
duction of  a  searcher — the  process  of  crushing  is  again  resorted  to, 
and  the  resulting  comminutions  treated  as  before   until  the  entire 

D6  is  removed.  The  last  fragments  not  infrequently  elude  the 
grasp  of  the  instrument,  and,  were  it  not  that  they  can  be  heard 
to  strike  the  evacuating  catheter  when  the  water  is  drawn  upward, 
their  existence  might  not  be  known.  If  the  curved  tube  be  used, 
the  beak  should  be  turned  from  side  to  side  to  present  its  eye  to 
different  aspects  of  the  bladder,  while  the  square-ended  tube  of 
passed  just  beyond  the  neck  of  the  bladder,  and  its  exter- 
nal extremity  is  well  lowered  between  the  thighs.     It  is  better  some- 


436 


OPERATIVE   SURGERY. 


times  to  allow  these  fragments  to  remain  until  the  patient  has  re- 
covered from  the  operation,  and  then  seek  for  them  again,  than  to 
continue  indefinitely  the  attempt  to  secure  the  last  one  at  the  first 
sitting.  Very  small  fragments  which  escape  detection  are  not  infre- 
quently passed  with  the  urine  within  four  or  five  days  after  the  oper- 
ation. 

The  limit  of  time  to  which  the  first  crushing  may  be  prolonged  is 
not  an  arbitrary  one ;  an  hour  or  two  is  not  unusual,  and  even  a 
longer  time  may  be  employed.  However,  an  hour  is  a  safe  rule  to 
adopt. 

After  the  operation  the  patient  is  kept  quiet  in  bed  and  well 
wrapped  ;  if  retention  occurs,  it  is  relieved  by 
a  catheter. 

Sequels. — Litholapaxy  has  various  sequels 
— rigors,  retention  of  urine,  cystitis,  impaction 
of  stone  in  the  urethra,  pyaemia,  atony  of  the 
bladder,  suppression  of  urine,  etc. — all  of 
which  should  be  treated  on  general  principles. 
Under  ordinary  circumstances  the  patient  will 
be  up  and  around  at  the  end  of  a  week  or  ten 
days. 

Results. — The  rate  of  mortality  is  about 
three  and  one  half  per  cent. 

Combined  Crushing  and  Evacuating  In- 
strument.— The  idea  of  the  possible  utility  of 
such  an  instrument  suggested  itself  to  me 
some  time  since,  after  a  somewhat  annoying 
effort  on  my  part  to  seize  the  "  last  fragment," 
the  existence  of  which  could  be  easily  and 
quickly  demonstrated  by  the  characteristic 
click  against  the  eye  of  the  evacuating  cath- 
eter during  the  washing-out  process.  I  also 
recalled  the  fact  that,  on  other  occasions,  the 
suction-force  of  the  washer  had  been  tempo- 
rarily arrested  by  the  closure  of  the  eye  of  the 
evacuating  catheter  by  a  fragment  of  calculus. 
The  male  blade  of  an  ordinary  litho trite  is 
modified  to  fit  the  anterior  or  concave  wall  of 
the  ordinary  evacuating  catheter,  which  is 
lined  with  a  brass  tube.  The  washer  can  be 
easily  connected  with  the  catchers  of  the  in- 
strument, as  shown  by  the  cut  (Fig.  677). 
It  is  not  expected  that  this  instrument  can 
supplant  the  lithotrite.  The  idea  is  to  crush 
combined  instrument.         the  stone  at  the  first  introduction  of  the  lith- 


OPERATIONS   OX   THE   URINARY   BLADDER. 


437 


otrite  as  effectually  as  practicable,  and  to  introduce  the  combined 
instrument  instead  of  the  ordinary  evacuating  catheter.  By  means 
of  this  the  detritus  is  removed  from  the  bladder,  and  such  of  the  re- 
maining fragments  as  are  caught  in  the  throat  of  the  instrument  are 
crushed  and  likewise  removed.  It  thus  becomes  possible  to  avoid 
the  interchange  of  instruments  incident  to  repeated  crushings.  With 
an  assistant  to  manipulate  the  washer,  the  operator  can  devote  his 
entire  attention  to  crushing  the  fragments  caught  in  the  throat  of  the 
instrument. 

When  applied  to  an  extemporized  bladder  it  worked  admirably, 
and  seemed  to  require  only  the  perfecting  influences  of  repeated  and 
practical  applications  to  create  for  it  a  place  among  the  recognized 
appliances  for  the  performance  of  litholapaxy. 

Perineal  Lithotrity. — A  stone  may  be  crushed  by  gradual  or  rapid 
lithotrity  through  an  opening  in  the  perineum.  Perineal  lithotrity 
has,  as  yet,  been  rarely  adopted  as  a  primary  method  of  treatment. 


Fig.  678. — Dolbcau's  method,  first  step. 


but  rather  as  an  expedient  to  facilitate  the  removal  of  a  stone  too 
large  to  be  removed  through  the  incision  made  for  the  purpose  of  a 
limple  lithotomy.  It  has  been  advocated  as  a  substitute  for  lithotomy, 
because  the  crushing  and  the  use  of  the  washing  apparatus  can  be 


438 


OPERATIVE   SURGERY, 


Fig.  679. — Dolbeau's  method,  second  step. 

substituted  for  the  incision  through  the  deeper  parts.     Still,  the  with- 
drawal of  an  ordinary  sized  stone  can  hardly  compare,  in  point  of 


Fig.  6S0. — Dolbeau's  method,  third  step. 


OPERATIONS   ON   THE   URINARY   BLADDER. 


439 


danger,  to  the  repeated  introduction  of  instruments  and  the  necessary- 
prolongation  of  the  operation  of  crushing  through  an  open  wound. 
However,  it  is,  without  doubt,  an  expedient  which  should  he  more  fre- 
quently adopted,  especially  for  the  removal  of  large  stones  through  an 
opening  too  small  to  admit  of  their  safe  withdrawal. 


Fio.  681.— Goulcy's  lithoclasts. 

Professor  Dolbeau  systematized  this  method.  The  incision  is  made 
through  the  perineum,  as  in  median  lithotomy,  after  which  the  dilata- 
tion ie  divided  into  three  steps,  the  dilator  of  Mr.  Dolbeau  being 
employed.  The  first  step  consists  in  the  dilatation  of  the  tissues 
down  to  the  groove  in  the  staff  (Fig.  678)  ;  the  second,  the  dilatation 
of  the  tissues  nearly  through  the  neck  of   the  bladder  (Fig.   C79)  ; 


440 


OPERATIVE   SURGERY. 


third,  the  withdrawal  of   the  staff  and  carrying  the  dilator  in  suffi- 
ciently to  thoroughly  dilate  the  neck  of  the  bladder  (Fig.  680). 

The  dilatation  in  all  the  steps  must  he  done  carefully,  and  in  ac- 
cordance with  the  resistance  encountered.  After  it  is  completed  a 
lithoclast    (Fig.   681)  of  suitable   size  is  introduced,   and   the   stone 

fragmented,  after  which  it 
conies  away  with  the  urine. 
A  small  reverse  current  of 
carholized  water  thrown  into 
the  bladder  will  wash  the 
fragments  out. 

The  results,  while  very 
satisfactory,  are  not  equal  to 
those  of  litholapaxy. 

Lithotrity  in  the  Female. 
— The  absence  of  the  prostate 
body,  and  the  shorter  and 
larger  urethra  of  the  female, 
combine  to  secure  a  more 
complete  emptying  of  the 
bladder,  and  also  lessen  the 
liability  in  the  female  to  the 
formation  of  vesical  calculi. 
A  stone  in  the  female  bladder 
can  not  be  grasped  with  the 
same  facility  as  that  in  the 
male,  owing  to  the  difference 
in  the  normal  shape  and  sur- 
roundings of  the  bladder,  and 
to  the  pathological  modifica- 
tions to  which  its  cavity  is 
subjected,  due  to  its  connec- 
tions with  the  uterus  and  va- 
gina, and  their  physiological 
and  pathological  variations 
caused  by  child-bearing  and 
its  sequels.  The  greater  lia- 
bility to  a  sacculated  base 
requires  that  the  instrument 
be  reversed  more  frequently 
than  in  the  sterner  sex.  The  operation  can,  however,  be  readily  per- 
formed, and,  aside  from  the  slight  variations  in  the  manoeuvres  neces- 
sary to  catch  the  stone,  differs  but  little  from  that  in  the  male. 

Lithotomy. — Lithotomy  is  the  operation  for  the  removal  of  stone 
from  the  bladder  by  cutting.    The  varieties  of  incision  in  common  use 


Figs.  682,  683.— Dolbeau's  dilator, 


OPERATIONS   ON    TIIE   URINARY   BLADDER. 


441 


are  classed  as  the  lateral,  median,  and  bilateral,  together  with  the 
occasional  employment  of  the  supra-pubic  method. 

Lateral  Lithotomy. — Lateral  lithotomy  is  employed  in  preference 
to  the  median,  when  the  stone  is  too  large  to  be  easily  removed  through 


Fig.  685. — Dupuytren's  knife 


Fig.  686.— Blizard's  knife. 


Fig.  687.— Blunt  gorget. 


""uuui  ■  ii,..!,m;  . , . 


Fig.  688. — Scoop  and  conductor. 


the  dilated  prostate.  The  instruments  necessary  for  the  operation  are 
I  Btafi  of  suitable  size,  with  the  proper  curve  and  a  deep  groove  upon 
it-  convexity  which  approaches  its  right  lateral  aspect  as  it  nears  the 
extremity  of  the  beak  (Fig.  684)  ;  a  bistoury  with  a  stout  blade  and 
handle,  a  solid  shank,  a  sharp  point,  and  a  cutting  edge  of  about  two 
inches  in  length  ;  a  probe-pointed  knife — the  one  devised  by  Bliz- 
ard  being  the  best — and,  if  the  perineum  be  deep,  due  to  obesity,  the 
>t  may  be  selected  ;  forceps  of  various  sizes  and  shapes  to  seize  the 
■  .  one  of  which  should  be  arranged  with  crossed  handles  to  avoid 
stretching  the  parte  about  the  neck  of  the  bladder  when  the  stone  is 
grasped.  It  ii  likewise  well  to  be  provided  with  a  small  lithoclast,  for 
the  purpose  of  breaking  those  stones  too  large  to  be  extracted  with 


442 


OPERATIVE   SURGERY. 


safety  ;  a  scoop  to  dislodge  the  remaining  fragments  of  stone  (Fig. 
692),  and  a  syringe  to  wash  from  the  bladder  any  small  fragments  that 


II 


>89.— Straight 
forceps. 


Fig.  690.— Curved 
lithotomy  forceps. 


Fig.  691.— Dol- 
beau's  lithoclast. 


Fig.   692.— 
Luer's  scoop. 


may  remain  (Fig.  693).  Davidson's  syringe  can  be  used,  but  is  less 
satisfactory  than  one  designed  for  the  purpose.  The  chemise  or 
shirted  canula  (Fig.  694)  is  useful  to  control  hemorrhage.  At  least 
five  assistants  should  be  present.  To  one  of  these  the  staff  should  be 
intrusted  ;  the  lower  limbs  may  be  held  by  two  others,  either  with  or 
without  the  limbs  being  confined  by  the  anklets  (Fig.  695).  The 
hands  and  feet  may  be  bandaged  together  satisfactorily  for  the  pur- 
pose. Of  the  remaining  assistants,  one  should  attend  the  instru- 
ments, and  the  other  the  sponges,  etc.  The  more  modern  device  for 
separating  the  lower  limbs  and  exposing  the  perineum  will  be  of 
great  service  (Fig.  696). 

Operation. — Shave  and  disinfect  the  parts,  empty  the  rectum  with 


OPERATIONS   OX   THE    URINARY   BLADDER. 


443 


an  enema,  administer  an  anaesthetic,  draw  the  patient  down  to  the 
edge  of  the  table,  and  confine  the  extremities.  The  staff  is  then  in- 
troduced and  the  stone  found  ;  a  diagnosis 
which  should  be  verified  by  others  present. 
If  the  stone  be  not  detected,  the  staff  should 
be  withdrawn,  and  its  presence  and  location 
determined  by  the  searcher.  These  points 
must  likewise  be  confirmed  by  others. 

If  the  stone  be 
not  found  at  all,  the 
operation  must  be 
deferred. 

The  principal  as- 
sistant, who  holds 
the  staff,  should  sat- 
isfy himself  that  the 
sound  touches  the 
stone,  although  it  is 
not  necessary  that  it 
be  pressed  against  it 
during  the  opera- 
tion. The  holder  of 
the  staff  should  stand 
at  the  patient's  left 
and  press  it  firmly 
beneath  the  pubes 
with  the  right  hand, 
while     the    integu- 


Fig.  603. — Van  Buren's 
debris  syringe. 


694. — Chemise  cath- 
eter. 


ment  of  the  perineum  is  made  tense  by  drawing  up  the  scrotum  with 
the  left.  The  convexity  of  the  staff  is  easily  felt  in  the  perineum.  If 
the  perineum  be 
thin  the  groove 
may  be  distinctly 
defined.  Some  sur- 
geons have  advised 
that  the  staff  be 
pressed  against  the 
perineum  instead  of 
the  pubes,  to  bet- 
ter define  its  out- 
line. However,  it 
is  a  matter  of  little 
importance  which 
course  is  taken,  so 
long  as   the  pubes 


Fig.  695.— Pritchard's  anklets  and  wristlets. 


444 


OPERATIVE   SURGERY. 


is  hugged  by  the  instrument  while  the  incision  is  being  made  into  the 
bladder.  The  surgeon  should  sit  upon  a  low  stool,  and,  before  begin- 
ning the  incision,  carefully  map  out  the  location  of  the  bulb,  and  the 
point  where  the  incision  is  to  begin,  also  determine  the  outlines  of  the 
rami  and  tuber  ischii.  He  then  introduces  the  index-finger  of  the  left 
hand  into  the  rectum,  locates  the  apex  of  the  prostate,  and  determines 
its  relations  to  the  sound.  The  finger  is  withdrawn,  disinfected,  and  the 
groove  in  the  staff  again  located.  The  incision  is  commenced  a  little  to 
the  left  of  the  median  raphe,  from  an  inch  and  a  quarter  to  an  inch  and 
a  half  in  front  of  the  anus.  The  point  of  the  knife  is  made  to  enter 
the  groove  at  the  second  or  third  cut,  being  guided  by  the  nail  of  the  in- 


Fig.  696. — Clover's  crutch  applied. 


dex-finger  of  the  left  hand.  The  perineal  incision  is  made  from  three 
to  three  and  a  half  inches  in  length,  and  carried  obliquely  downward, 
midway  between  the  tuber  ischii  and  the  verge  of  the  anus  (Fig.  708,  h). 
The  urethra  is  then  freely  opened,  and  the  probe-pointed  bistoury 
substituted  for  the  scalpel ;  or,  the  blunt  extremity  of  the  Blizard's 
knife  is  engaged  in  the  groove — when,  the  surgeon,  taking  the  han- 
dle of  the  staff  in  the  left  hand,  lowers  it  somewhat,  and  holding 
it  firmly  carries  the  knife  toward  the  bladder,  depressing  its  handle 


OPERATIONS   ON    THE   URINARY   BLADDER. 


445 


slightly  to  correspond  to  the  curve  of  the  staff.  If  he  were  to  push 
the  knife  downward  and  backward  without  depressing  its  handle,  the 
point  would  leave  the  staff  and  pass  behind  the  bladder,  a  fact  which 
would  not  be  discovered  until  the  withdrawal  of  the  knife  and  the  at- 
tempt to  pass  the  finger  into  the  bladder.  As  soon  as  the  end  of  the 
knife  is  stopped  by  the  termination  of  the  end  of  the  groove  in  the 
staff,  its  haudle  is  depressed,  the  edge  turned  still  more,  and  the  deep 
tissues  severed  from  within  outward  by  its  withdrawal,  care  being  taken 
to  make  the  incision  through  the  prostate  more  horizontal  than  that 
of  the  perineum  (Fig.  697).  The  flow  of  urine  which  follows  assures 
the  operator  of  successful  entrance  to  the  bladder. 

It  is  recommended  to  press  the  point  of  the  scalpel  firmly  against 
the  groove  in  the  staff  with  the  right  hand,  seize  the  staff  with  the 
left,  depress  the  handle  of  the  staff  and  the  knife  at  the  same  time,  to 
the  same  extent,  and  thus  convert  them  for  the  moment  into  one  in- 
strument which  is  pushed  into  the  bladder.  This  course  is  often  fol- 
lowed, and  will  prevent  the  escape  of  the  point  of  the  knife  from  the 
groove.     It  is  more  difficult,  however,  to  properly  lateralize  the  knife 

in  its  passage  through  the  pros- 
tate in  this  than  by  the  former 
method ;  besides,  it  is  much 
less  elegant.  The  purified  in- 
dex-finger of  the  left  hand  is 
now  passed  carefully  into  the 
bladder  along  the  staff,  which 
is  then  withdrawn.  The  neck 
of  the  bladder  is  dilated  by  the 
finger,  the  stone  reached,  and 
its  diameter  estimated,  if  it  has 
not  been  done  before.  If  it 
exceeds  an  inch  in  diameter, 
the  right  side  of  the  prostate 
should  be  nicked  by  introduc- 
ing a  knife  along  the  finger. 
The  forceps  are  now  passed  in 
as  the  finger  is  withdrawn,  and 
the  stone  carefully  grasped  in 
the  short  diameter.  If  one 
blade  of  the  forceps  be  pressed 
upon  the  floor  of  the  bladder,  and  the  instrument  opened,  the  stone 
will  often  roll  properly  within  its  grasp.  However  this  may  be,  un- 
11  - u.i I  caution  mnst  be  employed  not  to  bruise  the  contracted  walls 
of  the  empty  riflCBB.  If  the  stone  he  grasped  in  its  long  axis,  it  should 
he  dropped  and  the  direction  corrected  by  the  finger  carried  into  the 
bladder.     The  change  in  direction  may  sometimes  be  accomplished  by 


Via.  697. — Lateral  incision  of  prostate. 


446  OPERATIVE   SURGERY. 

carrying  two  fingers  into  the  rectum,  separating  and  pressing  them 
upward  against  the  bladder,  thereby  compressing  its  sides  and  creat- 
ing a  furrow  running  antero-posteriorly,  into  which  the  corresponding 
long  axis  of  the  stone  will  drop.  When  properly  grasped  it  is  with- 
drawn by  steady  traction  made  in  the  line  of  the  incision  through  the 
perineum.  Lateral  movements  can  be  made  with  direct  traction.  If 
inordinate  traction  be  deemed  necessary  for  its  removal,  it  should  be 
crushed,  after  which  it  can  be  easily  extracted.  Too  great  traction 
may  tear  off  the  neck  of  the  bladder,  or  lacerate  the  tissues  beyond 
the  limits  of  the  prostate;  still,  tearing  is  safer  than  extensive  cut- 
ting, since  the  plexus  of  veins  is  less  liable  to  be  injured  by  it.  As 
soon  as  the  calculus  is  removed,  its  surface  is  examined  for  facets, 
which  indicate  the  presence  of  still  one  or  more  calculi  in  the  bladder. 
Having  removed  all  the  calculi,  irrigate  the  bladder  with  tepid  car- 
bolized  water  to  remove  all  blood-clots  and  whatever  detritus  may  be 
present.  If  earthy  matter  exist  in  the  bladder,  it  may  be  necessary  to 
remove  it  with  a  scoop.  If  the  stone  be  encysted,  it  is  very  difficult 
and  often  impossible  to  remove  it.  It  may  be  grasped  with  the  for- 
ceps with  or  without  nicking  the  confining  structure ;  in  either  in- 
stance great  care  and  judgment  must  be  exercised.  If  arterial  hemor- 
rhage occur,  it  may  be  checked  by  ice-pressure,  by  the  devices  pre- 
viously illustrated,  or  by  the  ligature  ;  if  these  fail,  the  serrefine  forceps 
(Fig.  54)  may  be  clasped  to  the  bleeding  point  and  allowed  to  remain. 
The  tying  in  of  a  tenaculum,  or  acupressure,  will  check  it ;  venous 
hemorrhage  may  be  controlled  by  the  chemise  catheter  or  some  other 
similar  expedient.  After  the  operation  place  the  patient  in  bed  with 
a  rubber  cloth  beneath  the  hips,  separated  from  the  body  by  cloths, 
to  collect  the  urine  and  indicate  the  occurrence  of  hemorrhage.  The 
temporary  introduction  of  a  catheter  or  drainage-tube  into  the  blad- 
der through  the  wound  in  the  perineum  is  not  commonly  practiced. 


Fig.  698.-- -Smith's  lithotome. 


Give  light  and  stimulating  diet,  alkaline  drinks,  and  treat  all  sequelae 
on  general  principles. 

Results. — The  rate  of  mortality  ranges  from  six  to  ten  per  cent. 


OPERATIONS   ON   THE   URINARY   BLADDER. 


447 


The  operation  just  described  is  the  one  usually  employed.  There 
are,  however,  instrumental  modifications  which,  in  the  opinion  of 
some,  may  deprive  it  of  the  little  danger  that  may  arise  even  with  a  care- 
ful adherence  to  the  details.  The  instrument  devised  some  years  ago 
by  Dr.  Smith,  of  Baltimore,  and  successfully  employed  by  him  and 
others  (Fig.  G98),  is  worthy  of  mention.  It  consists  of  a  rectangular 
staff  with  a  well-rounded  angle,  and  is  deeply  grooved  on  its  horizontal 
portion,  and  provided  with  an  indicator  attached  to  the  shaft  by  means 
of  a  hinge.  The  indicator  is 
likewise  rectangular  and  ter- 
minates in  a  lance -shaped 
blade.  The  indicator  can  be 
adjusted  by  sliding  it  up  and 
down  the  staff ;  or  various 
sizes  of  the  instrument  may 
be  employed  to  meet  indi- 
vidual differences.  The  staff 
is  introduced  and  held  by  an 
assistant  in  the  usual  man- 
ner, and  the  cutting  extrem- 
ity of  the  indicator  is  ap- 
plied to  the  median  line  and 
pushed  through  the  tissues, 
until  it  lodges  in  the  groove 
of  the  staff.  The  probe- 
pointed  gorget  is  then  passed 
into  the  groove  and  lodged 
in  the  channel  on  the  staff, 
along  which  a  cut  is  made 
into  the  bladder.  A  probe- 
pointed  bistoury  may  be  sub- 
stituted for  the  gorget.  The 
single  and  double  lithotomes 
(Figs.  699  and  700)  have  their 
advocates.  They  are,  how- 
ever, in  a  small  minority 
when  compared  with  the 
number  of  adherents  of  the 
scalpel  and  grooved  staff. 

.  \fedian  Lithotomy.  — Me- 
dian  lithotomy  is  applicable 
to  cases  having  oneor  more  small  stones  half  an  inch  or  so  in  diam- 

.  and  in  advancing  puberty.  In  this  method  there  is  less  danger 
from  hemorrhage,  much  better  control  of  the  urine  from  the  first,  and 
the  wound  heals  rapidly.     If  the  stone  be  larger  than  was  anticipated, 


Fig.  099. — Dupuytrcn's 
double  lithotome. 


Fig.  700  — Hutchinson's 
lithotome. 


448 


OPERATIVE   SURGERY. 


the  temptation  to  use  violence  during  the  extraction  is  great.     It  is 
claimed  that  this  method  may  be  followed  by  stricture  of  the  urethra, 


Fig.  701. — Little's  lithotomy  staff. 


Fig.  702. — Mar- 
koe's  staff. 


Fig.  703- — Rectangu- 
lar staff. 


and  also  that  the  mouths  of  the  seminal  ducts  are  more  likely  to  be 
injured  than  by  the  other  methods.     The  general  precautions  to  be 

employed  in  all 
forms  of  lithot- 
omy are  men- 
tioned more  fully 
in  connection  with 
the  lateral  opera- 
tion. 

The  instruments  required  are  the  staff,  director,  and  knife.     The 
staffs  vary  somewhat  in  the  shape  and  depth  of  the  grooves.     The 


Fig.  704. — Little's  director. 


OPERATIONS   ON   THE   URIXARY   BLADDER. 


449 


ones  devised  by  Drs.  J.  L.  Little  (Fig.  701)  and  T.  M.  Markoe  (Fig. 
70:2)  leave  nothing  to  be  desired.  The  rectangular  variety  (Fig.  703) 
can  be  used  in  lieu  of  the  curved  one,  although  it  is  rarely  employed  in 
this  country.  The  director  devised  by  Dr.  Little  is  an  admirable  instru- 
ment (Fig.  704),  but  is  by  no  means  essential  to  a  successful  operation. 


— Little's  lithotomy  bistoury. 

A  stout,  straight,  sharp  bistoury,  double-edged  at  the  point  (Fig.  705), 
for  making  the  perineal  incision,  makes  the  especial  outfit  complete. 

Operation. — Confine  the  patient  in 
the  lithotomy  position  (Fig.  696)  ;  intro- 
duce the  staff,  placing  the  end  of  the 
beak  in  contact  with  the  stone  ;  pass  the 
left  index-finger  into  the  rectum,  and 
locate  the  apex  of  the  prostate  just 
where  the  staff  enters  it  ;  introduce  the 
point  of  the  knife  into  the  median  line 
of  the  perineum  half  an  inch  in  front 
of  the  anus  (Fig.  708,  a),  with  the  long 
cutting  edge  uppermost,  and  push  it 
carefully  upward  to  the  apex  of  the 
prostate,  guided  by  the  finger  in  the  rec- 
tum, into  the  groove  of  the  staff.  The 
knife  is  advanced  sufficiently  toward  the 
bladder  to  nick  the  apex  of  the  prostate, 
after  which  it  is  carried  forward  to  di- 
vide the  membranous  portion  of  the  ure- 
thra. The  external  incision  should  be 
from  one  and  a  quarter  to  one  and  a  half 
inch  in  length,  care  being  taken  to  avoid 
the  bulb  of  the  urethra.  The  director  is 
then  passed  into  the  bladder  along  the 
staff,  and  the  neck  of  the  bladder  moder- 
ately dilated  by  separating  the  two.  The 
staff  is  then  withdrawn,  and  the  index- 
linger  of  the  left  hand  carried  through 
the  neck  along  the  director  with  a  semi- 
rotary  mot  ion  to  complete  the  dilatation. 
The  forceps  an  then  introduced,  the 
stone  caught  at  its  short  diameter,  and 
removed     by    steady,     gradual     traction, 

which  may  be  accompanied  by  rocking  movements,  but  never  by  a  ro- 
tation of  the  instrument  on  its  long  axis  while  grasping  the  stone. 
2'.) 


Fig.  706.— Wood's  staff  aud 
bisector. 


4oO 


OPERATIVE   SURGERY. 


Fig.  707. — "Wood's  bisector. 


Various  instruments  have  been  devised  to  dilate  the  prostate  in 
this  and  other  methods  calling  for  the  procedure  (Figs.  682  and  683), 

all  of  which  an- 
swer the  purpose 
well,  but  are  by 
no  means  essential 
to  the  safe  per- 
formance of  the 
operation.  After  the  removal  of  the  stone,  stop  all  hemorrhage,  seek 
for  anv  remaining  calculi,  wash  out  the  bladder,  place  the  patient  in 
bed  with  the  limbs  extended,  administer  an  anodyne,  and  maintain 
quietude. 

Bilateral  Method. — The  preliminary  preparations,  the  precautions, 
and  general  arrangements  in  this  are  similar  to  those  necessary  in  the 
other  methods.  The  special  instruments  are  the  grooved  staff,  and 
the  bisector,  so  intimately  associated  with  the  name  of  the  late  Prof. 
James  R.  Wood  (Figs.  706  and  707). 

Operation. — Make  a  semilunar  incision  across  the  perineum,  three 
fourths  of  an  inch  in  front  of  the  anus,  beginning  midway  between 
the  anus  and  the  tuberosity  on  the  right  side,  and  terminating  at 
a  similar  point  on  the   opposite  side  (Fig.   708,  c).     The  convexity 

of  the  cut  is  directed 
forward.  The  several 
tissues  are  divided  down 
to  the  membranous  ure- 
thra, which  is  opened 
and  the  beak  of  the  in- 
strument inserted  in 
such  a  manner  as  to 
cause  the  beveled  edges 
of  the  bisector  to  be  up- 
permost. After  moving 
the  beak  backward  and 
forward,  to  be  certain  it 
is  well  lodged  in  the 
groove,  it  is  then  firmly 
pressed  against  the  groove  of  the  staff,  and,  with  the  staff  held  firmly, 
it  is  carried  into  the  bladder.  They  may  be,  practically,  converted 
into  a  single  instrument  by  pressing  them  firmly  together  and  carry- 
ing them  both  in  at  the  same  time,  being  careful  to  depress  the  handle 
of  each  to  the  same  degree. 

Fallacies. — The  bisector  may  be  carried  behind  the  bladder  if  any 
tissues  exist  between  the  groove  and  its  probe-pointed  extremity,  or  if 
the  handle  be  not  depressed  to  conform  with  the  long  axis  of  the  staff. 
The  anterior  wall  of  the  rectum  may  be  cut.     Avoid  this  accident  by 


Fig.  70S. — External  incisions  in  perineal  lithotomy. 


OPERATIONS   OX   THE   URINARY  BLADDER. 


451 


inserting  the  index-finger  of  the  left  hand  into  the  bowel  when  the 
primary  incision  is  being  made.,  and  drawing  the  anterior  wall  back- 
ward while  the  cut  is  being  completed. 

Tlie  remits  obtained  by  this  method  in  the  hands  of  Dr.  Wood 
were  equal  to,  if  not  better  than,  those  previously  given  in  connection 
with  the  other  methods  of  cutting  for  stone. 

Nelaton's  Modification. — Xelaton  modified  the  first  step  of  the 
bilateral  method,  with  the  view  of  lessening  the  danger  of  cutting  the 
bulb  and  the  wall  of  the  rectum.  He  introduced  the  left  index-finger 
into  the  rectum,  placed  the  end  of  it  against  the  apex  of  the  prostate, 
and  steadied  the  anterior  border  of  the  anus  with  the  thumb  of  the 
same  hand.  He  then  made  a  semilunar  incision  in  front  of  the  anus, 
the  extremities  of  which  were  four  fifths  of  an  inch  from  the  opening, 
and  the  greatest  convexity  three  fifths  of  an  inch  from  it.  The  dissec- 
tion was  continued,  layer  by  layer,  the  wall  of  the  rectum  and  the 
bulb  being  carefully  avoided,  until  the  membranous  urethra  was 
reached  and  opened,  and  the  cutting  instrument  introduced.  The 
same  object  was  accomplished  through  a  transverse  incision  an  inch 
and  a  quarter  in  length,  with  its  center  located  three  fifths  of  an  inch 
in  front  of  the  anus. 

Medio-Lateral  Operation. — This  method  was  devised  by  Buchanan, 
of  Glasgow. 

The  instruments  necessary  are  a  rectangular  staff  with  a  broad 
groove  in  its  left  side,  and  a  narrow,  straight  knife  with  a  long  edge. 
The  staff  is  introduced,  and  the  prominent  staff-angle  adjusted  to  cor- 
respond to  the  muco-cutaneous  junction  on  the  anterior  verge  of  the 
anus  in  the  median  line. 

The  instrument  is  then  firmly  held  with  the  handle  inclined  toward 
the  abdomen,  and  the  tissues 
are  penetrated  by  the  knife, 
held  horizontally  and  with 
the  edge  turned  to  the  left, 
until  the  groove  in  the  staff 
is  reached  (Fig.  709);  then 
the  knife  is  pushed  forward 
into  the  bladder  upon  the 
staff.  As  it  is  withdrawn,  an 
incision  three  fourths  of  an 
inch  long  is  made  downward 
arid  outward  toward  the  fore 
part  of  the  tuber  ischii.     This 

incision  is  completed  by  being  continued  directly  downward  about  half 
an  inch.     If  necessary,  it  can  be  extended. 

/:,  nils. — A  little  over  ten  per  cent  are  reported  to  have  died  after 
operation.-:  \>y  this  method. 


Fig.  709. — Medio-lateral  method. 


452 


OPERATIVE   SURGERY. 


Medio-Bilateral  Operation.  —This  method  was  brought  to  the  notice 
of  the  profession  by  Civiale,  and  has  since  been  championed  in  this 
country  by  Dr.  W.  F.  Briggs,  of  Nashville.  The  staff  for  the  median 
method  is  introduced  with  the  patient  placed  in  the  usual  position  ; 
the  rectum  is  drawn  backward  by  the  finger,  and  an  incision  made 
through  the  median  line  into  the  staff  an  inch  and  a  half  in  length, 
beginning  about  half  an  inch  in  front  of  the  anus. 

The  lithotome  (Fig.  710,  a)  is  then  introduced  into  the  groove,  car- 
ried into  the  bladder,  the  blade  expanded  half  an  inch,  and  the  instru- 
ment withdrawn,  enlarging  the  wound  on  either  side  a  quarter  of  an 
inch  throughout.  The  wound  is  then  dilated  and  the  stone  removed 
in  the  usual  manner.  If  too  large,  it  may  be  crushed.  The  author 
has  modified  Briggs'  instrument  somewhat  by  introducing  an  inde- 
pendent guiding  stem,  which  leaves  the  cutting  blades  uninterfered 
with  during  the  withdrawal  of  the  instrument  from  the  bladder  (Fig. 
710,  b). 


Fig.  710. — Briggs'  modified  lithotome. 


Results. — Prof.  Briggs  reports  his  mortality  as  at  the  rate  of  one  in 
thirty-seven  cases  operated  upon.  These  are  certainly  astonishing  results. 

Supra-Pubic  Lithotomy. — The  supra-pubic  or  high  operation  was 
done  first  by  Frere  Come,  about  1560.  Since  this  time  it  has  found 
favor  at  several  epochs,  and  is  now  again  being  strongly  advocated  by 
prominent  surgeons.  The  various  relapses  of  the  method  depended, 
without  doubt,  more  upon  the  determination  of  its  exponents  to  make 
it  an  exclusive  operation,  than  upon  its  own  intrinsic  defects. 

The  following  are  a  few  of  the  many  conditions  said  to  call  for 
this  method  :  Great  prostatic  hypertrophy ;  inability  to  extract  the 
stone  through  the  perineum  on  account  of  its  size  ;  encysted  stone, 
large  stone  with  a  contracted  bladder  surrounding  it  firmly ;  imper- 
meability of  the  urethra.  The  practical  objections  to  it  may  be  limit- 
ed to  these  two — operation  on  an  obese  patient,  and  one  with  a  con- 
tracted bladder  containing  a  small  stone.  The  possibilities  of  urinary 
extravasation — which  is  rare — and  of  cutting  the  vesico-abdominal 
reflection  of  peritoneum,  are  the  practical  dangers. 


OPERATIONS   ON   THE   URINARY   BLADDER.  453 

Operation. — Place  the  patient  on  the  back,  and  anaesthetize  to 
complete  insensibility  to  overcome  the  contractility  of  the  bladder. 
This  is  first  washed  out,  and  then  moderately  distended  with  a  warm 
four-per-cent  solution  of  boric  acid.  The  amount  injected  will  de- 
pend on  the  capacity  as  well  as  the  irritability  of  the  organ  ;  usu- 
ally sis  or  seven  ounces  will  suffice.  The  rectal  balloon  is  next 
introduced — the  ordinary  colpeurynter  will  do — and  distended  with 
warm  water  sufficiently  to  raise  the  bladder  well  above  the  pubes. 
An  incision  three  or  four  inches  in  length  is  then  made  in  the  median 
line,  commencing  just  above  the  pubes.  The  various  tissues  are 
divided  down  to  the  linea  alba,  which  is  cut  through  and  the  interspace 
between  the  pyramidal  muscles  is  sought  for.  If  it  be  not  found, 
the  muscular  fibers  should  be  separated,  when  the  fatty  layer  on  the 
transversalis  fascia  and  the  fold  of  peritoneum  will  make  their  appear- 
ance. Divide  the  fat,  draw  up  the  peritoneum  with  the  finger,  and, 
after  passing  a  strong  ligature  through  each  side  of  the  bladder  and 
looping  it,  to  provide  a  means  to  control  the  opening  to  be  made  into 
it,  open  the  bladder  with  a  bistoury,  in  the  median  line.  The  hemor- 
rhage, which  may  at  first  be  severe,  subsides  as  the  bladder  contracts 
and  empties  itself.  Introduce  the  finger  into  the  bladder  and  locate 
the  stone.  The  forceps  are  now  introduced  into  the  bladder  along  the 
finger,  the  stone  seized  and  removed.  If  it  is  necessary,  enlarge  the 
opening  ;  it  should  be  extended  downward.  Examine  the  bladder  for 
remaining  calculi,  and  cleanse  the  wound.  Some  surgeons  sew  the 
wound  in  the  bladder  with  catgut,  carried  down  to  but  not  through 
its  mucous  membrane.  The  abdominal  wound  is  then  closed  with  deep 
and  superficial  sutures,  and  dressed  antiseptically.  The  bladder  should 
be  evacuated  once  in  two  or  three  hours  during  the  first  three  days ; 
after  this  it  may  be  done  less  frequently  and  at  the  end  of  a  week  dis- 
continued. It  is  strongly  recommended — and  justly,  too,  it  seems  to 
me — to  leave  enough  of  the  visceral  and  abdominal  wounds  open  to 
admit  the  introduction  into  the  bladder  of  a  long  drainage-tube,  and, 
by  keeping  the  patient  on  the  side,  thus  avoid  the  use  of  the  cathe- 
ter. The  use  of  the  drainage-tube  is  open  to  the  objection,  however, 
that  a  small  amount  of  urine  will  escape  beside  it,  in  spite  of  the  great- 
ire.  It  is  also  advised  to  sew  the  lips  of  the  visceral  wound  to 
the  borders  of  the  abdominal  wound,  thus  to  surely  prevent  urinary 
extravasation.  Opposed  to  this  last  plan  is  the  possible  effect — as  yet 
uncertain — on  the 
function!  of  tin: 
bladder      of      the 

anion  Of     it*    walls      \j  Fio.  7ll.-Aponcurotome. 

with    tlio-';    of    the 

abdomen.     The  round  -lion Id  always  be  dressed  with  antiseptic  care, 
irrespective  of  the  method  employed.     The  opening  through  the  linea 


454 


OPERATIVE   SURGERY. 


alba  may  be  made  with  the  aponeurotome  (Fig.  711),  or  by  the  ordi- 
nary scalpel.  The  sonde  a  dart  (Fig.  712)  may  be  introduced  into 
the  bladder  and.  its  trocar  pushed  through  the  anterior  wall,  thus  serv- 
ing as  a  good  guide.  The  hooked  gorget  (Fig.  713)  is  useful  to  hold  up 
the  bladder,  and  keep  the  wound,  open  while  the  stone  is  being  removed. 

Results. — The  rate  of  mortality  as  reported  by 
some  is  about  one  in  four.  These  estimates  are, 
however,  deceptive,  since  they  relate  principally 
to  the  results  gained  by  this  method  when  employed 
under  unfavorable  circumstances.  A  rate  of  one 
in  eight  or  nine  is  now  attained. 


Fig.  712. — Sonde  a  dart.  Fig.  713. — Hooked  gorget.      Fig.  714. — (jfross'  dilator. 


LITHOTOMY   IK   THE   FEMALE. 

Aside  from  the  method  of  crushing,  a  stone  may  be  removed  from 
the  bladder  of  the  female  by  rapid  dilatation  of  the  urethra,  or  by 
urethral  and  vesico-vaginal  lithotomy.  The  method  by  dilatation  is 
performed  with  the  aid  of  the  finger  or  an  instrument  (Fig.  714)  espe- 
cially designed  for  the  purpose.  A  calculus  an  inch  or  more  in  diam- 
eter can  be  removed  in  this  manner  without  unfavorable  results.  The 
operation  of  lithotomy  is  not  difficult  of  execution  in  the  female. 


OPERATIONS   OX   THE   PENIS   AND   SCROTUM.  455 

Operation. — Introduce  a  broad-grooved  director  into  the  bladder, 
pass  upon  it  a  straight  probe-pointed  bistoury,  and  cut  directly  up- 
ward toward  the  symphysis  pubis.  Follow  the  incision  by  dilatation, 
and  then  remove  the  calculus  with  forceps.  If  greater  space  be  re- 
quired, the  cut  may  be  extended  downward  and  outward  toward  the 
tuber  ischii. 

This  method  is  modified  by  combining  the  two  preceding  methods 
as  follows  :  first  dilate  the  urethra,  then  divide  either  its  anterior  or 
posterior  wall  as  best  suits  the  indications  of  the  case,  and  remove 
the  stone. 

The  vesico-vaginal  method  consists  in  simply  connecting  the  vagina 
with  the  cavity  of  the  bladder  by  a  longitudinal  incision  made  in  the 
median  line  of  the  vagina,  the  length  varying  according  to  the  size  of 
the  stone.  A  grooved  staff  is  introduced  into  the  bladder,  the  position 
of  the  groove  ascertained  by  the  finger,  and  the  tissues  between  the 
finger  and  the  groove  are  divided  by  a  scalpel  or  scissors.  The  sequel 
which  contraindicates  the  vesico-vaginal  method  is  the  formation  of  a 
chronic  fistula.  It  is  claimed  that  the  wound  can  be  made  to  heal 
completely  if  the  parts  be  frequently  irrigated,  so  as  to  prevent  phos- 
phatic  deposits.  Tepid  water  acidulated  with  nitric  or  hydrochloric 
acid  will  aid  materially  in  the  prevention  of  the  deposit.  A  solution 
of  the  acetate  of  lead — one  grain  to  the  ounce  of  warm  water — is  also 
highly  extolled  for  this  purpose. 


CHAPTER  XVII. 

OPERATIONS   ON  THE  PENIS  AND   SCROTUM. 

Hydrocele. — This  morbid  condition  may  be  treated  by  tapping 
(which  is  palliative),  and  by  incision,  excision,  and  injection. 

Tap/iing  is  a  simple  process,  requiring  for  its  performance  a  small 
trocar  and  canula,  or  an  aspirating  needle,  or  an  instrument  of  a  simi- 
lar nature.  The  patient  is  caused  to  sit  upright  on  the  edge  of  a  chair 
with  the  limbs  separated,  the  enlargement  is  seized  by  the  left  hand, 
and  the  tissues  made  tense  on  its  anterior  surface.  The  testicle  is  care- 
fully located,  and  the  course  of  the  scrotal  vessels  as  carefully  avoided. 
The  instrument,  guarded  by  the  end  of  the  finger  (Fig.  715),  is  quickly 
plnnged  into  the  scrotnm  at  about  the  junction  of  its  middle  and 
lower  thirds.  As  the  fluid  escapes,  the  end  of  the  canula  is  turned 
away  from  the  testicle,  and  the  tumor  is  compressed  carefully  to  expel 
the  entire  fluid  collection.  After  the  fluid  is  removed  the  scrotum  is 
suspended,  and  the  patient  kept  quiet,  otherwise  inflammation  of  the 
sac  may  occur,  which,  while  it.  may  lead   to  a  radical  cure,  will  not  be 


456 


OPERATIVE   SURGERY. 


welcome,  as  it  causes  much  pain  and  confines  the  patient  to  bed.     It 
will  be  necessary  to  repeat  the  operation  in  five  or  six  months. 

Fallacy. — The  testicle  may  be  punctured  by  the  trocar,  unless  the 
exact  location  of  the  fluid  has  been  determined  by  transmitted  light. 

Incision. — In  this  operation  the  sac  is  laid  freely  open  on  the  ante- 
rior surface,  and  the  wound  dressed  from  the  bottom.     It  heals  in 

from  four  to  six  weeks,  and  is  seldom 
followed  by  a  return  of  the  disease. 
It  is  of  especial  efficacy  when  it  is  de- 
sired to  examine  the  pathological  con- 
dition of  the  testicles,  with  the  view 
of  determining  the  relation  of  a  sus- 
pected morbid  process  to  the  fluid 
collection.  Volkmann  incised  the  tis- 
sues under  antiseptic  precautions,  and 
stitched  the  sac  to  the  scrotal  incis- 
ion. This  operation,  like  the  preced- 
ing one,  has  been  followed,  though 
rarely,  by  a  return  of  the  disease. 

Excision. — In  this  method  a  por- 
tion of  the  sac  is  cut  away  on  either 
side  of  the  primary  incision.     As  a 
modification  it  allows  a  freer  escape 
of  the  discharges,  and  prevents  the 
protrusion   of    the  rigid  tunic,   but 
otherwise  makes  no  practical  difference.     The  external  incisions  in  the 
preceding  methods  may  be  made  either  long  or  short ;  the  former  is 
the  better,  as  it  affords  more  suitable  drainage. 

The  wounds,  after  all  of  these  operations,  may  be  treated  anti- 
septically  with  most  satisfactory  results. 

Incision  with  Excision. — This  method  differs  but  little  from  the 
one  last  mentioned,  and  is,  in  my  opinion,  the  best  operative  proced- 
ure for  the  radical  cure  of  hydrocele.  A  long  incision  is  made  into 
the  tunica  vaginalis,  under  the  bichloride  douche,  and  the  condition 
of  the  testis  ascertained.  The  rigid  protruding  borders  of  the  divided 
tunic  are  then  excised  in  the  direction  of  the  long  axis  of  the  external 
incision,  and  the  remaining  portions  stitched  by  catgut  to  the  sub- 
cutaneous scrotal  tissues  at  the  borders  of  the  long  incision.  A  drain- 
age-tube is  introduced,  the  scrotal  wound  closed,  and  the  scrotal  flaps 
quilted  together  by  catgut  sutures  to  prevent  the  contractions  of  the 
dartos  from  disturbing  the  union,  the  whole  is  then  dusted  with  iodo- 
form, and  surrounded  by  antiseptic  gauze. 

Prognosis. — The  wound  usually  heals  completely,  in  a  week  or  ten 
days,  under  the  primary  dressing,  without  any  suppuration  ;  and  the 
probability  of  a  return  of  the  disease  is  very  remote. 


Fig.  715. — Tapping  hydrocele. 


OPERATIONS   OX   THE   PENIS   AND   SCROTUM. 


457 


Injection. — The  fluids  recommended  are  numerous,  among  which 
iodine,  sulphate  of  zinc,  and  carbolic  acid  are  preferred  at  tte  present 
time.  The  instrument  required  in  the  performance  of  the  operation  is 
the  rubber  injection-bag.  in  addition  to  the  ordinary  trocar  (Fig.  716). 
The  trocar  is  introduced  and  the  fluid  drawn  off.  The  eac  is  then 
seized,  together  with  the  scrotal  tissues,  to  prevent  the  escape  of  the 
extremity  of  the  trocar  from  the 
cavity  of  the  sac,  and  the  medicated 
fluid  is  thrown  in  by  means  of  the 
gum  bag.  If  the  tincture  of  iodine 
be  used,  it  may  be  diluted  with  three 
or  four  parts  of  water.  Three  or 
four  ounces  of  the  mixture  is  quite 
sufficient  to  come  in  contact  with 
the  entire  surface.  It  should  be  re- 
tained for  five  or  ten  minutes,  until 
the  patient  complains  of  pain,  and 
rlien  allowed  to  escape  through  the 
canula.  If  the  pure  tincture  be 
used,  a  drachm  or  two  injected  in 
the  same  manner,  and  allowed  to  re- 
main and  become  absorbed,  is  quite 
sufficient.  If  the  sac  be  small,  fifteen 
or  twenty  drops  may  be  thrown  into 
it  by  a  hypodermic  syringe,  without 
the  previous  removal  of  the  fluid. 

If  the  sulphate  of  zinc  be  used, 
a  solution  composed  of  a  drachm  of 
the  salt  to  the  pint  of  water  is  of 
sufficient  strength. 

A  drachm  or  two  of  a  ten-  to  fif- 
ty-per-cent  solution  of  carbolic-acid 
crystals  in  glycerine  maybe  injected 
and  allowed  to  remain.  This  plan 
i-  strongly  advocated  at  the  present 
time  by  competent  observers. 

The  afrr-r-tivatmcnt  in  these  cases  consists  in  putting  the  patient  in 
bed,  suspending  the  scrotum,  and  keeping  lead  and  opium  applied  to 
it,  with  anodynes  to  allay  pain.  For  obvious  reasons,  the  congenital 
hydrocele  should  not  be  treated  radically  until  its  communication  with 
the  abdominal  cavity  is  closed. 

Accidents. — If  care  be  not  taken,  the  fluid  may  be  thrown  into 
the  connective  tisane  of  the  scrotum  instead  of  the  sac.  If  the  canula 
slip  out  after  the  fluid  is  withdrawn,  a  fresh  puncture  must  be  made, 
since  the  previous  opening  will  be  closed  by  the  contraction  of  the 


Fig.  710. — Rubber  bag  for  injecting. 


458 


OPERATIVE   SURGERY. 


dartos.  Suppuration,  sloughing,  etc.,  which  rarely  follow,  should  be 
treated  upon  general  principles.  The  results  fpllowing  all  of  the 
enumerated  methods  of  operation  are  nattering ;  yet  failures  are  not 
unknown  in  the  best. 

Castration. — Castration  is  an  operation  simple  of  performance  and 
free  from  danger.  Shave  and  disinfect  the  parts  ;  place  the  patient 
upon  the  back  and  administer  an  anaesthetic.  Make  an  incision  in  the 
long  axis  of  the  tumor,  beginning  just  below  the  external  abdominal 
ring  and  extend  it  to  the  lower  extremity  of  the  scrotum.  The  tis- 
sues are  carefully  divided  on  a  director  down  to  the  cord,  which  should 
always  be  cut  off  short,  if  the  operation  be  done  for  malignant  dis- 
ease. The  three  arteries  accompanying  it  should  be  tied  separately 
with  catgut  ligatures.  If  any  doubt  exists  as  to  their  having  been 
pronerly  secured,  the  cord  should  be  isolated  and  transfixed  by  a 
needle  armed  with  a  strong  catgut  ligature,  each  half  tied  separately, 
and  the  cord  divided.  If  it  be  divided  low  down,  each  vessel  can  then 
be  tied  separately.  In  cases  where  it  is  divided  high  up,  it  must  be 
secured  before  its  division,  otherwise  it  may  retract  and  seriously  com- 
plicate the  final  treatment. 

After  the  division  of  the  cord,  the  testicle  can  be  easily  removed 
from  the  enveloping  tissue  by  means  of  traction  and  an  occasional 
use  of  the  scissors.  All  bleeding  is  then  stopped,  a  small  drainage- 
tube  is  inserted  into  the  lower  edge  of  the  wound,  which  is  united  by 
fine  catgut  or  carbolized  silk,  and  the  wound  is  dressed  antiseptically. 
If  hemorrhage  of  the  cord  occurs  afterward,  the  dressing  must  be 
removed  and  the  wound  opened,  and  enlarged  if  it  be  necessary  in 
order  to  secure  the  bleeding  vessels. 

Circumcision. — When  phymosis  or  a  simple  redundancy  of  the 
foreskin  exists,  circumcision,  or  some  modification  of  this  operation, 


Fig.  717. — Henry's  phymosis  forceps. 


Fig.  718. — Fisher's  phymosis  forceps. 


should  be  performed.  The  instruments  especially  designed  for  the 
purpose  consist  of  the  variously  formed  clamps  (Figs.  717,  718),  a 
grooved  director,  and  probe-pointed  scissors  (Fig.  719).  The  patient 
is  placed  on  the  back  and  an  anaesthetic  administered,  or  a  cocaine 


OPERATIONS   OX   THE   PEXIS   AND   SCROTUM. 


459 


solution  injected  into  the  prepuce,  unless  a  determination  is  expressed 
to  endure  the  pain  without  it.  The  object  of  the  operation  is  not  to 
remove  the  foreskin  so  as  to  leave  the  entire  glans  penis  exposed  after 


Fig.  719. — Taylor's  phymosis  scissors. 


recovery,  but  to  allow  sufficient  integument  to  remain  so  as  to  afford 
the  protection  characteristic  of  the  normal  prepuce.  The  situation 
of  the  base  and  apex  of  the  glans  should  be  determined,  and  with  a 
pen  or  pencil  an  oblique  line  drawn  corresponding  to  the  direction  of 
the  base  of  the  glans,  about  midway  between  it  and  the  apex,  upon  the 
integument.  The  foreskin 
is  then  drawn  downward, 
placed  between  the  blades 
of  the  clamp,  with  the 
line  just  made  correspond- 
ing to  the  lower  border  of 
the  blades,  care  being 
taken  to  not  include  the 
glans  in  its  grasp  (Fig. 
720).  The  clamp  is  tight- 
ened and  the  distal  por- 
tion severed  by  a  sweep 
of  the  scalpel.  The  clamp 
ii  now  removed,  and  the 

integument  retracts  to  or  a  little  behind  its  previous  location.  The 
mucous  membrane  which  still  covers  the  glans  (Fig.  721,  a)  is  slit  up 
on  a  grooved  director,  along  the  dorsum,  b,  and  trimmed  symmetrically 
on  either  side,  not  even  with  the  integument,  c,  but  near  enough  to  it 

so  that  when  it  is  turned  over  and 
.  ^ —  its  free  borders  are  stitched  to 
the  skin,  a  vermilion  border,  d, 
at  least  a  third  of  an  inch  wide, 
will  be  formed.  Before  the  sew- 
ing is  done,  the  mucous  mem- 
brane should  be  stripped  off  the 
glans  to  a  point  behind  the  coro- 
na, after  which  it  can  be  returned 
and  its  border  joined  to  the  integ- 


Fig.  720. — Clamping  foreskin 


Via.  721.— Stepi  of  circumcision. 


460 


OPERATIVE   SURGERY. 


ument  by  a  continuous  horse-hair  suture.  If  the  mucous  membrane 
grasps  the  glans  too  tightly,  endangering  the  occurrence  of  paraphi- 
mosis, it  must  be  slit  on  the  dorsal  surface  up  to  its  point  of  reflection, 
after  which  the  borders  are  joined  as  before  described.  The  complete 
division  along  the  dorsal'  surface  will  permit  the  prepuce  to  accommo- 
date itself  to  the  varying  dimensions  of  the  penis  that  not  infrequent- 
ly occur  during  the  process  of  healing. 

Another  admirable  method  (Keyes),  which  is  intended  to  meet  the 
same  indications,  is  represented  by  Fig.  722.     In  this 
the  mucous  membrane  is  not  slit  up,  but  both  it  and 
the  integument  are  shaped  to  correspond  to  the  out- 
lines 1,  2,  3,  and  4,  5,  6,  after  which  the  former  is  re- 
flected backward  and  joined  to  the  integument,  so  that 
1  shall  correspond  to  4,  2  to  5,  and  3  to  6.     This  plan 
does  not,  however,  insure  the  same  freedom  as  the  long 
dorsal  slit  just  described.     If  the  phymosis  be  not  at- 
tended by  an  elongation  of  the  foreskin,  a  cure  may  be 
effected  by  slitting  it  upward  on  the  dorsal  surface  to 
the  base  of   the  glans.     The  ear-like  projections  on 
either  side  are  then  trimmed  off,  and  the  mucous  and 
cutaneous  borders  stitched  to  each  other  (Fig.   723). 
Cullerrier  well  accomplished  the  purpose  in  this  con- 
dition by  subcutaneously  dividing  the  mucous  mem- 
brane in  three  or  four  places  by  means  of  blunt-pointed 
scissors,  the  blunt  point  resting  upon  the  glans,  while 
the  sharp  one  was  passed  between  the  membrane  and  the  integument. 
If  the  prepuce  be  short,  and  the  case  not  an  aggravated  one,  the  mu- 
cous lining  can  be  stretched,  and  even  torn  asunder, 
by  introducing  the  blades  of  dressing-forceps  be- 
tween the  glans  and  foreskin  and  expanding  them, 
after  which  the  foreskin  can  be  drawn  backward 
and  retained  until  healing  is  completed.     In  all  the 
methods  of  operating,   the  after-treatment  is  di- 
rected to  modifying  the  inflammation  and  prevent- 
ing the  occurrence  of  an  erection  of  the  penis. 

For  this  purpose,  cold  applications,  large  doses 
of  bromide  of  potassium,  and  anodynes  are  recom- 
mended. It  is  now  a  favorite  method  to  sew  the 
borders  of  £he  wound  with  a  continuous  suture  of 
fine  catgut,  dust  it  with  iodoform,  and   surround 


Fig.  722.— 
Keyes'  modifi- 
cation. 


Fig.  723.- 
slit. 


■Dorsal 


the 


organ 


with 


iodoform  gauze.     The  catgut  sutures  are  allowed  to  remain  until  ab- 
sorbed. 

In  one  case  I  now  recall,  local  and  general  medication  combined 
were  not  sufficient  to  control  or  hardly  mitigate  the  tendency  to  erec- 
tion ;  yet  this  tendency  was  effectually  controlled  by  employing  a 


OPERATIONS   ON   THE   PENIS   AND   SCROTUM. 


461 


nurse  to  watch  the  penis  while  the  patient  slept,  with  instructions  to 
awaken  him  at  the  first  indication  of  an  erection. 

Paraphymosis  (Fig.  72-i). — In  this  condition  the  foreskin  is  im- 
movably lodged  behind  the  corona  glandis,  so  as  to  cause  great  con- 
gestion and  oedema  of 
the  parts  if  not  relieved 
(Fig.  725),  and  the  con- 
dition may  even  termi- 
nate in  gangrene  and 
sloughing.  The  reduc- 
tion may  be  accom- 
plished as  follows  : 

Oil  the  parts  well, 
and  administer  an  an- 
aesthetic, if  necessary ; 
grasp  the  penis  behind 
the  constriction  with 
the  thumb  and  fingers 
of  the  left  hand,  and 
the  glans  with  the  tips 

of  the  thumb  and  fingers  of  the  right ;  press  the  glans  with  the  latter 
gradually  to  reduce  the  swelling,  then  draw  the  constriction  forward 
with  the  left,  while  the  glans  is  gradually  forced  through  it  with  the 
thumb  and  fingers  of  the  right  (Fig.  726).     If  the  constriction  be  not 


Fig.  724. — Paraphymosis. 


Fig.  725.— Results  of  the 
constriction. 


.  b  -t  mi  tbod  of  reduction. 


Fig.  727.— Second  method. 


462 


OPERATIVE   SURGERY. 


Fig.  728.— Third  method. 


great,  and  the  oedema  and  congestion  be  slight,  this  manipulation  will 
soon  effect  the  reduction.  When  the  part  is  corrugated  and  much 
swollen  by  long-standing  severe  constriction,  followed  by  inflammation 
and  plastic  oedema,  it  will  be  found  necessary  to  sever  the  constriction 

on  the  dorsal  surface  by  a 
sharp-pointed,  curved  bis- 
toury. In  all  cases  where 
much  oedema  exists,  acu- 
puncture should  be  per- 
formed, and  the  fluids 
squeezed  through  the  open- 
ings before  reduction  is  at- 
tempted. Other  methods  of 
grasping  the  penis  are  rec- 
ommended to  effect  the  re- 
duction of  the  foreskin 
(Figs.  727,  728). 

After  reduction,  thor- 
oughly cleanse  and  disinfect 
the  parts  ;  place  the  patient  in  bed,  with  the  penis  resting  upon  the 
abdomen,  and  dress  with  cooling  antiseptic  lotions. 

Amputation  of  the  Penis — Old  Plan. — Place  the  patient  on  his 
back  and  give  an  anaesthetic,  cause  an  assistant  to  retract  the  integu- 
ment somewhat,  transfix  the  corpora  cavernosa  transversely  by  an 
acupressure-pin  to  prevent  retraction  of  the  stump,  embrace  the  penis 
behind  the  seat  of  the  disease  by  a  clamp  (Fig.  729)  inclined  slight- 
ly forward,  and  re- 
move the  projecting 
portion  with  a  large 
scalpel,  by  cutting  ob- 
liquely downward  and 
forward  ;  secure  all 
the  bleeding  points, 
draw  out  the  mucous 
membrane  of  the  ure- 
thra, divide  it  trans- 
verselv,  and  stitch  it 


Fig.  729. — Bodenhamer's  clamp. 


to  the  integument  at  four  different  points,  to  prevent  its  contraction 
into  the  canal.  If  the  cavernous  bodies  bleed  too  freely,  the  hemor- 
rhage can  be  checked  by  acupressure.  If  the  amputation  be  made  too 
near  the  pubes  to  permit  the  application  of  the  clamp,  a  tape  or  cord, 
carried  behind  the  pin,  may  be  substituted. 

Hilton's  Modification  consists  in  dividing  the  spongy  body  about  a 
fourth  of  an  inch  in  front  of  the  cavernous  portion,  splitting  it  longi- 
tudinally, and  uniting  the  lateral  flaps  to  the  integument  as  before. 


OPERATIONS   OX   THE   PENIS   AND   SCROTUM.  463 

Humphrey's  Modification  consists  in  dissecting  up  the  skin  of  the 
penis,  and  turning  back  a  circular  flap  about  half  an  inch  in  length, 
dividing  the  corpora  cavernosa  on  a  level  with  the  attachment  of  the 
flap,  and  cutting  the  spongy  body  at  least  half  an  inch  longer  than 
the  preceding,  and  attaching  the  integument  to  its  extremity. 

If  the  amputation  is  to  be  made  close  to  the  symphysis,  two  acci- 
dents must  be  guarded  against,  viz.,  retraction  of  the  stump  and  infil- 
tration of  the  scrotum  with  urine.  If  a  stout  ligature  be  passed 
through  the  fibrous  sheath  of  the  penis,  a  little  above  the  point  of 
proposed  section,  the  first  accident  will  be  obviated.  The  infiltration 
can  be  prevented  by  dividing  the  scrotum  entirely  through,  in  the 
line  of  the  urinary  canal,  and  uniting  the  borders  of  the  integument 
to  those  of  the  urethra,  thus  forming  two  scrotums,  with  the  urinary 
opening  between  them. 

Extirpation  of  the  Penis  (Gouley). — Anaesthetize  the  patient,  make 
a  curvilinear  incision  on  either  side  of  the  root  of  the  penis,  beginning 
in  the  median  line,  about  one  inch  and  a  half  above  the  level  of  the 
pubes,  and  ecding  a  little  below  the  peno-scrotal  junction.  The 
cavernous  bodies  are  exposed  and  transfixed  with  a  large  knitting- 
needle,  or  with  a  suitable  substitute  ;  the  urethra  is  transfixed  by  a 
smaller  one  on  the  same  plane,  and  the  penis  is  amputated  an  eighth 
of  an  inch  in  front  of  them.  After  all  the  bleeding  points  are 
secured,  the  urethra  is  found  and  a  grooved  staff  introduced  through 
it  into  the  bladder.  A  sharp-pointed  scalpel  is  then  carried  through 
the  perineum  and  lodged  in  the  grooved  staff,  and  all  the  tissues,  in- 
cluding the  scrotum,  divided  from  behind  forward.  The  urethral 
cut  is  about  an  inch  and  a  half  in  length,  and  the  cutaneous  one 
three  inches.  The  urethra  is  now  detached  from  the  cavernous  bod- 
ies and  these  bodies,  together  with  their  crura,  are  dissected  away, 
after  which  the  borders  of  the  urethra  are  united  to  those  of  the 
perineal  wound. 

CONGENITAL    MALFORMATION    OF   THE    URETHRA. 

The  urethra  may  be  absent  or  occluded  ;  it  may  be  extremely  small 
or  bifid  ;  the  external  opening  may  be  higher  or  lower  than  normal, 
and  even  double  ;  its  walls  may  be  deficient  above  or  below,  consti- 
tuting epispadias  and  hypospadias.  Epispadias  is  sometimes  com- 
plicated by  separation  of  the  symphysis  pubis  and  exstrophy  of  the 
bladder. 

Hypospadias  results  from  a  deficiency  in  the  floor  of  the  urethra. 
The  opening  may  exist  in  the  glans  or  in  the  penile  or  scrotal  por- 
tions. The  first  form  i-  the  most  frequent  and  the  least  important. 
The  scrotal  is  the  next  in  point  of  frequency,  and  the  most  important 
of  all.  When  the  deficiency  is  in  the  anterior  or  balanic  portion,  the 
following  operation  will  give  satisfaction  : 


464 


OPERATIVE   SURGERY. 


Fig.  730. — Gouley's  method. 


Gouley's  Method  (Fig.  730). — Make  two  longitudinal  cuts,  2-3  and 
2-3,  far  enough  apart  to  leave  ample  material  for  the  new  urethra ; 

make  4-5  and  4-5  a  fourth  of  an  inch  out- 
side ;  remove  the  integument  of  the  spaces 
bounded  by  these  incisions  ;  leave  undis- 
turbed the  skin  and  mucous  membrane  in- 
cluded between  the  incisions  2,  3  at  1,  10  ; 
slide  the  loose  skin  at  the  root  of  the  penis 
and  of  the  scrotum  forward,  making  it 
double  upon  itself  until  3,  3  is  brought  to 
2,  2,  and  the  denuded  surfaces  are  brought 
in  accurate  apposition,  making  the  angle  of 
the  fold  at  7,  7.  The  first  suture  is  taken 
at  6,  6,  passing  through  the  upper  flap  from 
within  (beneath)  outward,  and  the  lower  flap 
or  border,  2,  3,  from  without  inward ;  before 
tying,  pass  the  suture  of  the  opposite  side  in 
the  same  manner ;  tie  both,  cut  the  ends 
short,  leaving  the  knots  inside  the  new  ure- 
thra ;  introduce  sutures  along  the  external 
borders,  uniting  3,  5,  9  to  2,  4,  8.  The  newly  formed  meatus  is  trans- 
verse, its  under  lip  being  the  fold  of  the  skin  from  10,  formed  by 
the  apposition  of  the  points  3,  3  to  2,  2.  If  the  opening  be  in  the 
penile  portion,  and  the  organ  bent  downward,  the  curve  must  first 
be  relieved  by  subcutaneous  section  of  the  tissues  while  the  penis  is 
forcibly  extended. 
If  transverse  incis- 
ions of  the  skin  be 
needed  to  aid  in 
overcoming  the  de- 
formity, they  will 
be  found  to  assume 
a  longitudinal  as- 
pect when  the  or- 
gan is  straight- 
ened, and  can  then 
be  united  by  su- 
tures. 

When  the  defect 
is  in  the  penile  portion,  the  following  method  is  worthy  of  trial  : 

Anger's  Method  (Fig.  731).— Make  an  incision  on  the  left  side  of 
the  penis,  from  the  glans  to  the  scrotum,  1,  2,  half  an  inch  from  the 
median  line,  also  incisions  at  1,  3  and  2,  4 ;  the  flap  thus  formed,  a, 
is  dissected  up,  its  base  being  attached  near  to  the  median  line,  3,  4. 
A  second  longitudinal  incision,  5,  6,  is  made  at  the  right  side  of  the 


Fig.  731. — Anger's  method. 


OPERATIONS   OX   THE   PENIS   AND   SCROTUM. 


465 


median  line,  near  to  it,  and  of  the  same  length  as  1,  2,  with  lateral 
incisions  an  inch  and  a  half  long  at  each  extremity,  5,  7  and  6,  8. 
The  ilaps  are  raised,  a  sound  introduced  into  the  urethral  groove,  and 
the  first  flap,  a,  turned  over  it,  bringing  the  integumentary  portion  in 
contact  with  the  urethral  sound.  Independent  sutures,  each  armed 
with  a  needle,  are  passed  through  the  free  margin  of  the  first  flap,  a, 
and  outward  through  the  base  of  the  second  flap,  b,  and  fastened  by 
shot  pressed  around  them.  The  remaining  flap,  b,  is  then  placed  upon 
the  raw  surface  of  the  first,  a,  and  fastened  to  the  margin  of  the  first 
incision,  1,  2.  The  sound  or  catheter  is  then  removed,  and  only  intro- 
duced thereafter  to  evacuate  the  bladder. 

Duplay's  Method  (Fig.  732). — This  operation  can  be  divided  into 
three  steps:  1,  if  the  penis  be  incurved,  it  is  straightened  and  a  new 


Fig.  732.— Duplay's  method 


meatus  made  ;  2,  the  missing  wall  of  the  urethra  is  restored  ;  3,  the 
old  and  new  portions  are  joined  together. 

The  penis  is  straightened  by  making  transverse  subcutaneous  in- 
cisions through  the  restraining  bands  while  the  organ  is  being  extend- 
ed ;  if  the  integument  be  too  taut  to  admit  of  the  proper  rectification 
of  the  organ,  it,  too,  must  be  severed,  the  resulting  cuts  united  in  the 
long  axis  of  the  penis,  and  the  penis  confined  in  the  corrected  posi- 
tion a  sufficient  time  to  permit  the  healing  of  the  wound  before  the 
second  step  of  the  operation  is  attempted. 

The  first  step  is  completed  by  freshening,  and,  if  necessary,  deep- 
ening the  urethral  groove  at  the  situation  of  the  proposed  meatus, 
and  uniting  its  raw  surfaces  by  silver  wire  or  carbolized  silk  around 
a  sound  or  gum  catheter  as  in  Thiersch's  method  (Fig.  73G). 

Second  Step. — Two  longitudinal  incisions  are  made,  3,  3,  extend- 
ing from  tin;  glana  to  near  the  abnormal  opening,  one  on  each  side  of 
the  urethral  groove,  at  a  distance  from  each  other  equal  to  half  the 
imference  at  the  proposed  urethra,  :i  dimension  which  can  be 

rtained  by  measuring  the  gum  catheter  over  which  the  flaps  are 
to  be  reflected.  Prom  the  ends  of  these  a  transverse  incision  is  made 
toward,  bat  Dot  quite  to,  the  median  line.  The  flaps,  1  and  2,  are 
BO 


4:66 


OPERATIVE   SURGERY. 


dissected  up  and  turned  inward  over  a  gum  catheter,  3  (transverse 
sections),  and  their  margins  fastened  together  in  the  median  line  by 
fine  sutures.  The  outer  flaps,  4  and  5,  of  the  longitudinal  incision 
are  dissected  up  sufficiently  to  permit  them  to  be  easily  drawn  over 
the  reflected  ones,  1  and  2,  when  they,  too,  are  united  in  the  median 
line  by  interrupted  or  continuous  sutures.  Unite  the  anterior  ex- 
tremities of  all  the  flaps  to  the  raw  borders  of  the  glans,  thus  com- 
pleting the  anterior  portion  of  the  tube. 

Third  Step. — Freshen  the  edges  of  the  abnormal  opening,  6,  and 
unite  it  to  the  posterior  extremities  of  the  flap  by  a  double  row  of  su- 
tures. 

Szymanoivski's  Method  (Fig.  733). — Make  an  incision,  1,  1,  near 
the  edge  of  the  fistula,  extending  half  an  inch  beyond  it ;   dissect 


Tig.  733. — Szymanowski's  method. 

up  a  flap  bounded  by  the  dotted  line ;  make  a  curved  incision,  2,  2, 
on  the  opposite  side,  its  length  being  a  trifle  less  than  that  marked  on 
the  dotted  line  upon  the  other  side,  but  otherwise  of  sufficient  width 
to  cover  the  fistula  and  reach  the  dotted  line  when  turned  upon  it- 
self ;  scrape  the  cuticle  from  the  flap  2,  2,  and  dissect  it  up  to  the 
edge  of  the  fistula ;  arm  each  end  of  a  fine  carbolized  silk  suture  with 
a  small  curved  needle  ;  pass  these  two  needles  from  the  epidermic  sur- 
face, about  a  quarter  to  a  sixth  of  an  inch  apart,  through  the  edge  of 
the  curled  flap  (Fig.  733,  h),  introducing  them  from  within  outward 
— corresponding  to  the  dotted  line — through  the  base  of  the  flap 
formed  by  the  straight  incision  ;  after  passing  a  sufficient  number  of 
these  sutures — one  every  quarter  inch — draw  the  curved  flap  beneath 
the  straight  one  into  the  space  formed  by  the  separation  of  the  latter 


OPERATIONS   ON   TIIE   PENIS   AND   SCROTUM, 


467 


733, 
edge 


Fig.  734. — Nclaton's  method, 


so  that  its  edge  will  correspond  to  the  dotted  curved  line  (Fig 
c),  and  secure  them  over  a  piece  of  quill  or  cork.      The  inner 
of  the  straight  flap  is  now  united  to  the 
outer  edge  of  the  curved  one,  and  the  opera- 
tion is  completed. 

Epispadias.  —  Epispadias  results  from  a 
deficiency  in  the  roof  of  the  urethra.  The 
ability  to  secure  as  satisfactory  results  in  this 
as  in  the  preceding  deformity  has  not  yet 
been  attained. 

Nelaton's  Method. — A  ligature  is  passed 
through  the  prepuce,  which  is  drawn  over 
the  end  of  the  penis  and  held  during  the  op- 
eration. An  incision,  1  and  2,  is  then  made 
along  each  side  of  the  urethral  gutter  at  the 
junction  of  the  skin  and  mucous  membrane, 
beginning  at  the  prepuce  and  ending  at  the 
abdominal  wall  (Fig.  734).  The  external 
lip  of  each   incision    is   dissected   outward 

about  a  sixth  of  an  inch  and  allowed  to  remain  continuous  with  the 
skin  ;  the  inner  lip  of  each  is  likewise  slightly  detached.  A  third 
flap,  3,  is  marked  out  upon  the  abdominal  wall,  its  base  being  located 

immediately  above  the  abnormal 
urethral  orifice,  between  two  ver- 
tical incisions,  which  are  connected 
above  by  a  transverse   one  ;   this 
flap  should  be  as  broad  as  and  a 
little  longer  than  the  penis,  and  be 
dissected  from   above   downward, 
It  is  then  turned  downward  upon 
the  dorsum  of  the  penis,  the  raw 
surface     being     uppermost    (Fig. 
735,  3),  and  the  cuticle  forms  the 
roof    of    the  new  urethra.       The 
borders  of  the  flap,  h  h,  are  now 
united  by  sutures  to  the  inner  lips 
of  the  incisions  on  the  dorsum  of 
the  penis  (Fig.  734,  g  g),  the  con- 
tact being  made  as  broad  as  pos- 
sible.    The  abdominal  flap  is  now 
735,  //),  which  is  limited  above 
incision  circumscribing  the  under  half  of  the  penis  at  the 
^-scrotal   junction,  and   below  by  a  curved  incision  located  the 
length  of  the  penis  below  the  upper  one,  each  extremity  remaining 
nnonj  with  the  integument  on  the  outer  surface  (Fig.  735,  e). 


e- 


786.— Nllaton'a  method. 


re-enforced  by  a  scrotal  one  (Fig. 


468 


OPERATIVE   SURGERY. 


This  flap  is  dissected  up,  the  penis  slipped  under  it,  and  its  raw  sur- 
face apposed  to  the  abdominal  one  already  in  position. 

The  outer  borders  of  the  scrotal  flap  are  now  united  to  the  borders 
of  the  external  flaps,  1,  2,  found  by  the  primary  incisions  made  along 
the  urethral  gutter. 

Thiersch's  Method. — This  method  comprises  four  distinct  steps, 
and  requires  several  months  for  its  completion. 

A  fistulous  opening  should  be  established  in  the  perineum  to  per- 
mit the  escape  of  the  urine  before  any  of  the  steps  are  taken. 

First  Step. — Formation  of  a  meatus  and  that  portion  of  the  canal 
occupying  the  glans. 

A  deep  incision  (Fig.  736,  1)  is  made  along  each  side  of  the 
urethral  groove,  in  the  glans,  and  the  surface  of  the  outer  lips  of  each 


Fig.  736. 


n        a 

-Thiersch's  method  :  forming  the  meatus 


incision  is  pared,  a  a,  2,  and  they  are  drawn  around  a  sound  or  cath- 
eter, brought  in  contact  with  each  other,  and  united  by  sutures  or 
hare-lip  pins,  a  (Fig.  73G,  3). 

Second  Step. — Formation  of  the  urethra. 

Make  an  incision  through  the  skin  and  subcutaneous  tissue  at  the 
edge  of  the  urethral  gutter  at  the  right  side,  3,  3  (Fig.  737) ;  also  a 


12\ 


&*§!• 


im 


vi 


Fig.  737. — Thiersch's  method. 


short  transverse  cut  outward  from  each  end,  3,  4.  Make  a  second  in- 
cision on  the  left  side  parallel  with  the  preceding  one  half  an  inch  ex- 
ternal to  the  edge  of  the  gutter,  1,  1,  and  a  transverse  one  at  each  ex- 
tremity, 1,  2,  extending  inward  to  the  border  of  the  groove.  The  flap, 
a,  is  dissected  up,  making  it  as  thick  as  possible.    The  flap  on  the  right 


OPERATIONS   ON   THE   PENIS   AND   SCROTUM.  469 

side,  b,  is  also  raised.  The  flap,  a,  is  now  turned  over  to  form  the  roof 
of  the  new  channel,  its  raw  surface  being  uppermost.  Several  sutures 
should  be  passed  through  it  near  to  its  free  margin,  in  the  manner 
previously  shown  (Fig.  731),  thence  through  the  base  of  the  flap  b, 
and  fastened  by  a  qnill  or  shot  attachment.  The  flap  b  is  then  drawn 
across  the  former  so  that  their  raw  surfaces  are  in  contact  throughout, 
and  its  free  margin,  3,  3,  joined  to  the  outer  side  of  the  incision,  1,  1, 
by  sutures. 

Fourth  Step. — To  close  the  posterior  portion  of  the  canal. 

This  opening  is  closed  by  two  flaps,  one  taken  from  each  groin. 
The  left  flap  is  shaped  like  an  isosceles  triangle.  Its  base  is  located 
at  the  left  half  of  the  opening,  and  when  turned  downward  forms  the 
roof  of  the  new  urethra.  The  right  flap  is  quadrilateral,  its  base 
being  located  at  the  right  external  abdominal  ring  ;  its  raw  surface  is 
placed  in  contact  with  the  raw  surface  of  the  fellow,  and  its  borders 
are  united  by  sutures  to  all  contiguous  borders.  After  the  healing  is 
completed,  the  perfection  of  the  canal  can  be  tested  by  temporarily 
closing  the  perineal  fistula  by  the  finger  during  micturition.  If  sat- 
isfactory, the  perineal  fistula  should  be  permanently  closed. 

ACQUIRED    URETHRAL   DEFECTS. 

The  walls  of  the  urethra  may  suffer  loss  of  substance,  producing  a 
fistula.  The  caliber  of  the  canal  may  be  diminished,  causing  strict- 
ure, either  of  which  usually  depends  upon  acquired  causes. 

Before  attempting  an  operation  for  the  closure  of  a  urethral  fis- 
tula, the  caliber  of  the  canal  should  be  made  as  near  to  its  normal  size 
as  possible  by  appropriate  treatment  of  the  strictures  and  such  other 
obstructions  as  may  exist. 

Urethroraphy. — This  operation  is  employed  to  close  a  small  ure- 
thral fistula,  not  exceeding  a  fifth  of  an  inch  in  diameter  if  it  be  cir- 
cular, and  one  fourth  if  longitudinal.  If  reasonable  success  is  to 
be  attained,  it  is  necessary  that  careful  attention  be  paid  to  every 
detail. 

Before  beginning  the  operation  empty  the  bladder,  and  if  necessary 
administer  an  anaesthetic. 

Operation. — A  sound  is  introduced  into  the  urethra  and  the  handle 
given  in  charge  of  an  assistant.  The  edges  of  the  opening  are  care- 
fully pared  obliquely,  and  when  completed  should  present  a  funnel- 
shape  appearance,  the  apex  corresponding  to  the  mucous  opening  of 
tin-  canal.  The  wound  is  then  closed  longitudinally  by  means  of  a 
fine  wire,  horse-hair,  or  antiseptic  silk,  carried  down  to,  but  not 
through,  the  mucous  lining  ;  the  intervals  between  them  being 
short. 

The  patient  should  be  kept  quiet  and  given  alkaline  and  demul- 
cent drinks,  and  the   urine  drawn  with  a  catheter.     It  is  a  wise  pre- 


470 


OPERATIVE   SURGERY. 


caution  to  inject  oil  into  the  urethra  before  the  introduction  of  the 
catheter,  to  protect  the  cut  as  much  as  possible  from  any  urine  that 
might  come  in  contact  with  it. 

Urethroplasty. — Urethroplasty  is  employed  to  close  larger  open- 
ings than  those  within  the  domain  of  urethroraphy. 

If  flaps  be  dissected  upon  either  side  of  the  opening,  and  drawn 
together  and  joined  in  the  median  line,  imperfect  union  is  very  apt  to 
result  on  account  of  their  thinness  and  median  contact.  To  over- 
come this,  it  has  been  proposed  to  pass  a  sheet  of  thin  rubber  above 
the  flaps  to  protect  them  from  the  urine  during  the  healing  process 
(Fig.  738).  If,  for  this  sheet-rubber,  thin  rubber-skin,  separated  from 
the  cut  surfaces  by  a  strip  of  Lister  gauze, 
be  substituted,  the  irritation  will  be  lessened 
and  the  prospect  of  success  correspondingly 
increased. 

Mlato7is  Method  (Fig.  739).— The  edges 
of  the  opening  are  first  pared,  and  then  the 
integument  is  detached  subcutaneously  for 
about  an  inch  around  it  by  entering  a  long, 
thin  knife-blade  through  a  transverse  cut  just 
below  the  opening  (Fig.  739).  The  liberated 
integument  is  then  joined  in  a  longitudinal 
fold  along  the  median  line  by  means  of 
quilted  sutures. 

Dieffendach,  instead  of  dissecting  subcuta- 
neously, raised  two  parallel  longitudinal  flaps 
and  fastened  the  middle  of  their  raw  under 
surfaces  together  by  sutures  passed  through  leather  supports  at  each 
side.     Two  or  three  rows  of  sutures  can  be 
used  instead  of  this. 

Delpech  dissected  up  a  single  flap,  drew 
it  across  the  fistula,  and  fastened  it  to  a  raw 
surface  prepared  on  the  opposite  side.  Ar- 
laud  made  two  transverse  flaps,  one  in  front 
and  the  other  behind  the  fistula,  about  an 
inch  and  a  half  in  width.  The  anterior  one 
was  dissected  up  toward  the  glans  about 
three  fourths  of  an  inch,  and  the  posterior 
one  back  over  the  scrotum,  until  it  could 
be  easily  drawn  forward,  so  as  to  cover  the 
fistula.  The  cutaneous  surface  of  the  an- 
terior portion  of  the  scrotal  flap  was  fresh- 
ened and  the  flap  drawn  forward  so  as  to  cover  the  fistula,  and  the  an- 
terior flap  drawn  backward  over  it  and  united  by  sutures. 

Rigaud  (Fig.  740)  closed  a  large  fistula  at  the  peno-scrotal  junc- 


38. — Urethroplasty. 


Fig.  739. — Nelaton's  method. 


OPERATIONS   OX   THE   PENIS   AND   SCROTUM. 


471 


tion  bv  the  method  employed  by  Nekton  in  the  treatment  of  epispa- 
dias. A  quadrilateral  median  flap,  with  its  base  adjoining  the  open- 
ing, was  taken  from  the  scrotum,  turned 
forward  over  the  fistula,  and  its  raw  sur- 
face covered  by  two  flaps  taken  from  the 
sides  and  drawn  together  so  as  to  meet 
in  the  median  line. 

tmanot08ki  suggested  that  the  cuta- 
neous surface  of  the  reversed  flap  be  blis- 
tered instead  of  scraped.  This  meth- 
od is  not  as  reliable,  however,  as  the 
former. 

External  Perineal  Urethrotomy,  some- 
times called  perineal  section,  is  employed 
in  the  treatment  of  intractable  strictures,  especially  when  accompanied 
by  a  urethral  fistula  located  in  the  perineum.     It  may  be  performed 


Fig.  740. — Rigaud's  method. 


Fig.  741. — Gouley's  beaked  bistoury. 


either  with  or  without  a  guide.  The  former  is  not  a  difficult  opera- 
tion, while  the  latter  is  frequently  an  extremely  perplexing  one.  The 
instruments  essential  for  the  operation  are  an  ordinary  scalpel,  also 


Fio.  71-'. — Gouley's  grooved  and  tunneled  catheter  staffs. 

.  :th  a  sharp  point  and  a  Long,  thin  blade,  the  beaked  bistoury  of 

741),  whalebone  guides,  a  groored  and  tunneled  catheter 

i  L2,  a,  &),  ordinary  sounds,  a  gum  catheter,  small  probe, 

director,  et  ipatnla,  tenacnla,  two  strong  ligatures,  each  armed 


472 


OPERATIVE   SURGERY. 


with  a  curved  needle,  and  the  usual  instruments  for  controlling  hem- 
orrhage. Syme's  grooved  staff  (Fig.  743)  is  objectionable,  in  that  its 
point  may  get  into  a  false  passage  and  the  stricture 
be  missed.  Moreover,  its  introduction  through  the 
stricture  is  more  difficult  than  that  of  the  whale- 
bone guide,  and  attended  by  greater  danger  to  the 
soft  parts.  If  the  ordinary  small-sized  grooved  staff 
employed  in  lithotomy  can  be  introduced,  nothing 
better  need  be  asked  for. 

Operation  with  a  Guide. — Evacuate  the  bowel, 
shave  and  cleanse  the  perineum,  administer  an  an- 
aesthetic, fill  the  urethra  with  olive-oil,  and  intro- 
duce a  whalebone  guide  into  the  bladder  in  the 
manner  before  described  (page  420) ;  over  this  pass 
the  grooved  and  tunneled  catheter  staff  down  to 
and  through  the  stricture,  if  it  can  be  done  readi- 
ly ;  if  not,  allow  its  beak  to  rest  against  the  ob- 
struction, carefully  supported  by  an  assistant,  who 
at  the  same  time  raises  and  holds  the  scrotum. 
The  patient  is  now  placed  in  a  lithotomy  position, 
and  the  limbs  supported  by  an  assistant  upon  either 
side.  The  surgeon,  sitting  upon  a  low  stool  facing 
the  perineum  of  the  patient,  introduces  the  left  in- 
dex-finger into  the  rectum  to  ascertain  the  condi- 
tion of  the  membranous  and  prostatic  portions  of 
the  canal.  A  free  incision,  from  an  inch  to  an 
inch  and  a  half  long,  is  then  made  in  the  median 
line  of  the  perineum,  extending  from  the  base  of 
the  scrotum  to  within  half  an  inch  of  the  anus, 
through  the  integument  and  fascia.  The  grooved 
instrument  is  carefully  located  by  the  finger,  and 
the  urethra  brought  into  view  by  repeated  cuts  in 
the  same  line.  The  nail  of  the  index-finger  assures 
the  surgeon  of  the  location  of  the  groove,  and  the 
urethra  is  divided  upon  it.  Two  silk  ligatures  are 
now  passed,  one  through  each  border  of  the  divided 
urethra,  and  are  then  looped  and  given  in  charge  of  the  assistants, 
who  are  instructed  to  carefully  draw  the  lips  of  the  wound  apart 
(Fig.  744).  This  important  step  exposes  the  mucous  wall  of  the 
urethra  completely,  enabling  the  operator  to  follow  its  course  by 
carefully  observing  the  continuity  of  its  structures.  The  staff  is 
now  withdrawn  sufficiently  to  show  the  black  guide,  then  the  beaked 
bistoury  is  introduced  in  its  course,  and  the  stricture,  together 
with  about  half  an  inch  of  the  canal  immediately  behind  it,  is  di- 
vided in  the  median  line. 


Fig.  *743. — Syme's 
grooved  staff. 


OPERATIONS   OX   THE   PENIS   AND   SCROTUM. 


473 


The  admission  of  a  grooved  director  or  a  small  gum  catheter 
through  the  opening  into  the  bladder,  followed  by  the  flow  of  urine, 
assures  the  surgeon  that  he  has  located  the  proper  channel ;  or,  after 


Fig.  744. — Borders  of  incision  drawn  apart. 

the  division  of  the  stricture,  the  tunneled  catheter  staff  may  be 
■d  along  the  whalebone  guide  into  the  bladder  and  the  stylet 
withdrawn,  when  the  diagnostic  urinary  stream  will  appear.  The 
instruments  are  now  withdrawn  from  the  urethra,  and  the  ordi- 
nary sound  of  suitable  size  is  introduced  into  the  neck  of  the  blad- 
der, through  the  urethra,  to  determine  the  complete  freedom  of  the 

Operation  without  a  Guide. — After  all  efforts  to  introduce  a  whale- 
bone guide  into  the  bladder  have  failed,  pass  the  tunneled  catheter 
itafl  oyer  a  whalebone  guide  along  the  urethra  as  far  as  it  will  go 
without  using  violence  ;  then  place  the  staff  and  guide  in  charge  of 
an  assistant,  as  before.  Make  an  incision  of  the  usual  length  directly 
in  the  median  line  down  to  and  through  the  urethra  into  the  groove 
at  the  end  "f  the  staff;  past  the  silken  loops  through  the  borders  oi 
the  incised  urethra  as  before;  check  :dl  hemorrhage,  wit  lid  raw  the 
slightly,  and  examine  t"  see  it*  it  lie  located  in  the  urethral  tube. 
Tin'  lip.-i  of  the  urethral  incision  are  now  drawn  well  apart,  and  the 


474  OPERATIVE   SURGERY. 

operator,  whose  patience,  care,  and  knowledge  must  now  be  well 
tested,  endeavors  to  introduce  a  whalebone  guide  or  a  fine  probe  or 
grooved  director  through  the  stricture  into  the  bladder  by  way  of  the 
perineal  incision.  If  the  effort  be  successful,  the  remainder  of  the 
operation  is  simple,  and  consists  only  in  dividing  the  stricture  with 
the  probe-pointed  bistoury  from  above  downward  as  before  ;  usually, 
however,  no  anterior  opening  can  be  found,  or  one  may  be  detected 
which  leads  away  from  the  median  line,  showing  the  existence  of  a 
false  passage. 

In  either  case  the  plan  of  the  operator  must  be  the  same.  Keep  in 
the  median  line.  If,  after  a  patient  search,  no  direct  orifice  be  found, 
it  is  often  possible  to  detect  it,  by  making  moderate  pressure  above 
the  pubes  on  the  bladder,  which  will  frequently  cause  a  few  drops  of 
urine  to  escape  from  the  obscure  opening  in  the  perineal  cut,  into 
which  a  whalebone  guide  or  a  fine  director  can  be  inserted,  and  usu- 
ally passed  into  the  bladder.  If  the  pressure  accomplishes  nothing, 
then  the  surgeon  feels  for  the  opening  in  the  triangular  ligament, 
through  which  the  urethra  normally  passes,  and  cuts  toward  and  even 
through  it  if  the  urethra  can  not  be  found  before.  As  he  cuts  he  re- 
peatedly seeks  for  the  orifice,  and  closely  examines  for  a  continuation 
of  the  fibrous  mass  in  the  line  of  his  incision  with  the  tissues  compos- 
ing the  walls  of  the  urethra.  In  the  obscure  division  of  the  amalga- 
mated perineal  tissues,  the  surgeon  is  also  guided  by  the  established 
relations  of  the  normal  urethra  to  the  arch  and  rami  of  the  pubes,  to 
the  tuberosities  and  rami  of  the  ischium,  and,  still  more  important, 
the  relations  to  the  rectum.  The  careful  cutting  and  searching  are 
continued  until  an  opening  is  found  which  leads  into  the  bladder. 
The  tissue  barring  the  passage  is  cut,  and  a  small  gum  catheter  is 
passed  along  the  probe  or  director  into  the  organ.  This  is  followed 
by  the  welcome  flow  of  urine.  The  catheter  is  then  withdrawn,  the 
canal  dilated  with  the  little  finger,  and  all  constricting  bands  at  the 
roof  and  floor  of  the  urethra  are  severed.  A  steel  sound  the  size  of 
the  canal  is  then  introduced  into  the  bladder  through  the  urethra 
several  times  until  its  uninterrupted  entrance  is  assured.  Increase 
the  size  of  the  meatus  and  divide  by  internal  urethrotomy  all  obstinate 
strictures  in  front  of  the  perineal  opening.  Examine  the  bladder  for 
stone,  and,  if  found,  remove  it ;  stop  all  bleeding ;  place  the  patient 
in  bed  with  hot  fomentations  to  the  abdomen  ;  elevate  the  scrotum  to 
prevent  infiltration  ;  administer  anodynes  and  demulcents,  and  keep 
the  patient  quiet.  The  major  portion  of  the  perineal  wound  may  be 
closed  by  antiseptic  sutures  carried  deeply,  leaving,  however,  sufficient 
room  for  the  introduction  of  a  large  flexible  catheter,  through  the 
neck  of  the  bladder.  The  wound  should  be  dressed  antiseptically. 
The  catheter  should  be  allowed  to  remain  in  position  for  four  or  five 
days,  unless  its  presence  causes  some  degree  of  vesical  irritation.    Suit- 


OPERATIONS   ON   THE   PENIS   AND   SCROTUM. 


475 


able-sized  sounds  should  be  passed  every  two  or  three  days  for  a  con- 
siderable time  at  a  later  period. 

Results. — In  eight  thousand  cases  of  external  urethrotomy  a  little 
oyer  five  per  cent  died. 

Internal  Urethrotomy. — The  division  of  strictures  by  cutting  in- 
struments introduced  into  the  urethra  is  called  "internal  urethroto- 


It  is  usually  limited  to  strictures  of  the  penile  portion,  although 
sub-pubic  and  even  those  of  the  membranous  portions  may  be  divided. 
The  number,  size,  location,  and  extent  of  the  obstructions  should  be 
determined  before  their  division  is  attempted. 

For  this  purpose,  bulbous  bougies  and 
urethrometers  have  been  devised.  The  me- 
tallic bougie  of  Otis  (Fig.  745),  and  also  the 
•  non-metallic  forms  (Fig.  746),  meet  the  indica- 

W  wl  tiffl  tions  admirably.  If  it  be  the  intention  of  the 
operator  to  distend  the  canal  to  its  fullest 
capacity,  and  if  the  meatus  be  undersized,  it 
should  be  slit  up  before  the  stricture  is  divided. 


Fig.  746. — Non-metallic  boucries. 


Fig.  747. — Civiale's  bistouri  cache. 


The  slitting  can  be  easily  done  by  means  of  the 
bistouri  cache  of  Civiale  (Fig.  7-47).  After  prop- 
erly distending  the  meatus,  it  is  introduced  with 
the  cutting  surface  downward,  and  quickly  with- 
drawn. The  ordinary  probe-pointed  bistoury, 
or  a  straight-edged  one,  with  the  end  guarded, 
will  accomplish  the  purpose  perfectly.  The  lips 
of  the  cut  will  unite  unless  they  be  kept  sepa- 
rated by  lint  or  cotton,  or  by  the  occasional  in- 
troduction of  a  large-sized  sound.  The  location, 
A  A  (\  number,  and  size  of  strictures  can  be  determined 
by  the  introduction  of  bulbous  bougies.  One  of 
large  .-i/.e  that  will  Blip  through  the  meatus  is 

cted,  oiled,  and  passed  down   the  canal  until 

arrested.     The  distance  in  the  canal  is  noted  on  the  handle.    It  is  then 

withdrawn,  and  the  lize  of  the  bull;  measured  by  the  Familiar  scale. 


476 


OPERATIVE   SURGERY. 


The  surgeon  next  ascertains  the  size  of  the  one  that  will  pass  the 
obstruction,  and  so  on,  recording  the  location  and  size  of  each  obstruc- 
tion in  its  turn  until  the  bladder  is  entered.  The  urethrometer  of 
Otis  (Fig.  748)  is  constructed  on  a  principle  calculated  to 
give  practically  accurate  measurements.  The  unexpanded 
blades  of  the  extremity  of  the  instrument,  B,  are  covered 
by  a  small  rubber  cap  or  closed  tube,  C  ;  the  instrument 
is  oiled  and  carried,  closed,  through  the  last  obstruction, 
if  possible,  when  the  extremity  is  expanded  by  a  screw  at 
the  outer  end  until  it  fills  the  urethra,  the  capacity  of 
which  is  noted  upon  the  dial  ;  it  is  slowly  withdrawn  while 
the  expanded  extremity  is  regulated  to  accommodate  the 
varied  dimensions  of  the  canal,  the  caliber  and  location  of 
which  should  always  be  noted.  By  this  simple  though 
ingenious  method  the  surgeon  is  enabled  to  locate  quite 
correctly  the  seat  of  the  obstacle  he  is  to  treat.  The  re- 
maining instruments  required  are  the  urethrotome,  and  a 
double-barreled  catheter,  to  apply  an  iced-water  current 
to  the  canal. 

Urethrotomes,  like  other  instruments  designed  for  spe- 
cial purposes,  vary  in  many  important  particulars.  Those, 
however,  of  greatest  practical  utility  were  devised  by  Otis 
and  Peet  (Figs.  749,  750,  and  751).  Each  bears  upon  its 
handle  a  scale  which  enables  the  operator  to  ascertain  not 
only  the  size  but  the  distensibility  of  an  obstruction. 
Either  of  these  instruments,  when  taken  in  connection 
with  the  urethrometer,  enables  the  surgeom  to  divide  the 
strictured  portions  until  the  scale  on  the  dial  or  handle  of 
the  cutting  instrument  indicates  that  the  strictured  por- 
tions of  the  urethra  correspond  in  size  to  the  dimensions 
of  the  normal  portions,  as  indicated  by  the  dial  of  tbe 
urethrometer. 

Operation. — An  anaesthetic  or  cocaine  solution  is  em- 
ployed, and  the  patient  is  placed  upon  the  back.  Then  a 
well-oiled  instrument  is  introduced,  and  the  extremity 
concealing  the  blade  is  carried  beyond  the  obstruction, 
thrometer.  which  is  dilated  by  turning  or  depressing  the  screw  at 
the  end  until  the  strictured  tissues  are  made  tense,  when 
the  knife  is  withdrawn  sufficiently  to  divide  the  stricture  freely.  The 
action  of  the  instrument  is  then  reversed  and  the  knife  pushed  back 
into  its  hiding-place,  and  the  instrument  again  dilated  to  note  the 
effect  of  the  incision  upon  the  caliber  of  the  stricture.  If  it  still  be 
below  the  standard,  as  indicated  by  the  urethrometer,  the  blade  is 
again  applied  to  it.  In  this  manner  each  constriction  can  be  divided 
and  the  tube  made  of  a  uniform  diameter  throughout.     If  two  or 


OPERATIONS   OX   TTIE   PENIS   AND   SCROTUM. 


477 


more  strictures  have  a  common,  or  an  almost  common,  diameter,  they 
can  be  cut  simultaneously  by  drawing  the  knife  along  the  course  of 

the  shaft.  There  is  little  danger  of 
cutting  the  healthy  mucous  mem- 
brane, so  long  as  the  dial  on  the 
urethrotome  indicates  a  smaller  di- 
mension than  that  of  the  normal 
urethra,  as  shown  by  the  urethrom- 
eter.       If    severe    hemorrhage    fol- 


'10,  750.— Otto*  urethrotomes. 


In;.  7">1. — Pect'B  urethrotome 


low,  a  large-sized  Bound  can  be  introduced,  and  the  penis  bandaged 
Cold  may  be  applied  by  means  of  a  stream  of  iced-water  con- 
ducted through  a  double-barreled  catheter.     It  is  sometimes  necessary 


478 


OPERATIVE   SURGERY. 


to  make  pressure  on  the  perineum,  in  conjunction  with  other  expedi- 
ents. The  necessity  for  this  is  extremely  rare.  Following  urethrot- 
omy the  patient  must 
be  kept  quiet  in  bed 
for  three  or  four 
days,  with  a  light 
diet  and  open  bow- 
els ;  demulcent  and 
alkaline  drinks  are 
often  advisable.  A 
sound  may  be  passed 
every  third  day  un- 
til the  wound  is 
healed.  Very  few 
patients  perish  as  the 
direct  result  of  in- 
ternal urethrotomy, 
and  when  carefully  done  upon  proper  cases,  an  unfavorable  result  need 
not  be  anticipated. 

Tapping  the  Urethra  (Cock). — In  a  distended  bladder  from  impass- 
able stricture  this  is  a  feasible  operation.  The  patient  is  placed  in  the 
lithotomy  position,  and  the  left  index-finger  introduced  into  the  rec- 
tum, and  its  tip  pressed  against  the  apex  of  the  prostate  (Fig.  752).  A 
double-edged  knife  is  then  plunged  into  the  perineum,  in  the  median 
line,  the  point  being  directed  to  the  tip  of  the  finger,  and  caused  to  open 
the  urethra  in  front  of  the  prostate,  behind  the  stricture,  by  a  slight  lat- 
eral motion.  As  the  knife  is  withdrawn,  the  dimension  of  the  wound 
may  be  increased  anteriorly.  A  grooved  director  is  then  carried  into 
the  bladder  through  the  opening,  and  a  catheter  passed  upon  it  to  re- 
lieve the  distended  viscus.  The  opening  may  be  made  through  the  an- 
terior wall  of  the  rectum  when  objections  exist  to  the  perineal  puncture. 


Fig.  752. — Tapping  the  urethra. 


CHAPTER  XVIII. 

MISCELLANEOUS   OPERATIONS. 


Tapping  the  Pericardium.— If  the  pericardium  be  hyper-distended 
by  fluid,  or  contain  pus,  and  the  attending  symptoms  denote  danger- 
ous heart  failure  from  pressure,  the  accumulated  fluid  may  be  removed 
by  tapping  or  by  aspiration  through  the  trocar  of  Fitch. 

The  instrument  devised  by  Dr.  Roberts,  of  Philadelphia,  who  has 


MISCELLANEOUS    OPERATIONS. 


479 


given  much  attention  to  the  subject,  is  well  adapted  to  the  purpose 
mentioned.  The  principal  operation  should  be  preceded  by  an  explor- 
atory puncture  with  a  hypodermic  syringe.  The  arteries  to  be  avoided 
are  the  mammary  and  intercostal ;  the  former  rests  upon  the  costal 
cartilages,  about  a  half  inch  from  the  outer  border  of  the  sternum,  the 
latter  run  along  the  lower  border  of  the  ribs.  The  point  of  the  instru- 
ment should  be  directed  away  from  the  apex  of  the  heart,  since  the 
latter  moves  from  left  to  right  and  from  behind  forward  at  each  pul- 
sation. 

Operation. — Place  the  patient  diagonally  upon  the  left  side,  with 
the  shoulder  and  chest  raised.  Insert  the  instrument  through  the 
fifth  intercostal  space,  an  inch  or  an  inch  and  a  half  from  the  left 
border  of  the  sternum,  close  to  the  upper  border  of  the  sixth  rib,  using 
great  care  to  prevent  the  entrance  of  air. 

Results. — Nearly  forty  per  cent  of  the  patients  have  recovered 
after  the  operation. 

Extirpation  of  the  Breast. — The  breast  is  removed  to  eradicate 
growths  of  a  malignant  and  non-malignant  character.  If  malignant, 
the  entire  gland  must  be 
extirpated.  If  non-ma- 
lignant, only  such  tissues 
as  are  involved  in  the 
growth  need  be  removed. 
If  the  growth  be  malig- 
nant or  of  a  doubtful 
character,  all  of  the  en- 
larged lymphatics  in  its 
vicinity  should  be  taken 
away.  Indeed,  it  is  wise 
under  these  conditions  to  remove  the  entire  axillary  system  of  lymphatic 
glands,  even  though  but  one  or  two  have  become  slightly  enlarged. 
The  shape  and  extent  of  the  growth  will  modify  the  outlines  of  the 
incisions.  If  it  be  irregular,  some  other  form  rather  than  the  estab- 
lished elliptical  cut  may  be  employed  (Figs.  753  and  754). 

Operation.  —  Wash  and  asepticize  the  part  and  its  immediate  sur- 
roundings ;  shave  the  axilla  if  the  examination  of  the  contents  be  con- 
templated ;  place  the  patient  on  the  back  and  administer  an  anaes- 
thetic.    Raise  the  arm  to  make  tense  the  fibers  of  the  pectoralis  major  ; 

-in'  a  position  relative  to  the  patient  which  will  be  most  convenient 
for  making  the  inferior  incision  first  (Fig.  755).  A  scalpel  of  large 
elected  ;  the  bread  pressed  upward  and  supported  by  the 
left  hand,  and  the  inferior  incision  made  iii  the  direction,  if  possible, 
<»f  the  fibers  of  the  pectoralis  major.  It  should  extend  down  to  the 
pectoral  fibers,  and  the  breasi  should  be  reflected  upward  from  them 

by  traction   with   the   hand,  aided  by  the  scalpel  when  necessary.      As 


Figs.  753,  754. — Incisions  for  removal  of  the  breast. 


480 


OPERATIVE   SURGERY. 


Fig.  755. — Removal  of  the  breast. 


soon  as  the  under  surface  of  the  tumor  is  raised,  the  upper  incision  is 
made  and  the  growth  removed.  The  amount  of  hemorrhage  is  some- 
times quite  ex- 
tensive ;  still,  it 
can  be  easily  kept 
under  control  if 
an  assistant  fol- 
lows the  course 
of  the  knife  with 
an  antiseptic  tow- 
el, making  firm 
pressure  on  the 
bleeding  points. 
Two  towels  are 
required,  one  for 
each        incision. 

After  the  removal  of  the  growth,  the  towels  are  cautiously  raised  from 
below  upward,  and  the  bleeding  points  secured  by  serresfines  as  soon 
as  seen.  Any  remaining  portions  of  the  morbid  growth  which  may 
be  attached  to  the  pectoral  fascia,  muscle,  etc.,  should  be  removed, 
even  at  the  complete  sacrifice  of  the  parts  with  which  they  are  con- 
nected. The  vessels  should  be  ligated  with  catgut.  If  any  enlarged 
glands  exist  in  the  axilla,  or  along  the  border  of  the  great  pectoral 
muscle,  they  should  be  removed  at  once,  together  with  all  of  their 
associates,  irrespective  of  their  size.  The  wound  must  be  properly 
drained  at  its  most  dependent  part,  united  with  silver  wire  or  carbol- 
ized  silk,  and  otherwise  treated  antiseptically. 

Results. — The  rate  of  mortality  from  removal  of  mammary  growths 
and  their  axillary  complications  is  about  seventeen  per  cent.  How- 
ever, this  mortality  is  offset  by  the  fact  that  the  operation  adds  twelve 
months  to  the  life  of  the  patient,  and  when  thoroughly  performed 
cures  about  nine  per  cent  (Prof.  S.  W.  Gross). 

The  mortuary  results  from  limited  extirpation  alone  are  practically 
the  same  as  those  following  complete  removal.  It  often  happens  that 
the  skin  is  too  extensively  diseased  to  admit  of  the  formation  of  a  suit- 
able flap.  The  wound  should  then  be  allowed  to  heal  by  granulation. 
Extirpation  of  the  Axillary  Glands. — This  operation  is  often  neces- 
sary when  the  lymphatic  glands  located  therein  become  enlarged, 
either  primarily  or  secondarily,  from  malignant  growths.  In  fact,  it 
is  wise  to  "clean  out"  the  space  whenever  one  or  more  of  these  glands 
is  enlarged  from  this  cause,  even  though  the  enlargement  be  slight  and 
of  recent  date.  Whenever  an  axillary  gland  is  found  to  be  enlarged, 
not  only  should  this  be  removed,  but  likewise  the  entire  series  should 
be  removed,  together  with  the  connective  tissue  supporting  them, 
simultaneously  with  the  removal  of  the  contiguous  malignant  growth. 


MISCELLANEOUS   OPERATIONS.  481 

Location  of  the  Glands. — These  glands  are  normally  of  compara- 
tively large  size,  are  from  ten  to  twelve  in  number,  and  are  surrounded 
by  loose  areolar  tissue.  There  are  three  chains  of  them  :  one,  surround- 
ing the  axillary  vessels,  which  receive  the  lymphatics  from  the  arm  ; 
another,  but  smaller  one,  runs  along  the  lower  border  of  the  pectoralis 
major  muscle,  and  receives  the  lymphatics  from  the  mammary  gland 
and  the  front  of  the  chest ;  the  last  chain  is  located  along  the  poste- 
rior border  of  the  axilla  and  receives  the  lymphatics  from  the  back. 
There  are.  in  addition  also,  two  or  three  larger  so-called  subclavian 
lymphatic  glands,  that  are  located  beneath  the  clavicle,  through  which 
the  axillary  and  deep  cervical  glands  communicate  with  each  other. 

Location  of  the  Vessels. — If  a  line  be  drawn  through  the  center  of 
the  long  axis  of  the  axilla,  the  important  vessels  and  nerves  will  be 
located  within  the  anterior  half  of  the  space.  It,  therefore,  follows 
that  all  deep  incisions  should  be  made  within  the  posterior  half,  the 
nearer  to  the  posterior  border  of  the  axilla  the  safer. 

Operation. — The  parts  should  be  always  shaven  and  scrubbed  be- 
fore the  operation.  The  operation  may  then  be  performed  either  by 
extending  into  the  axilla  the  incision  for  the  removal  of  the  primary 
growth,  or  by  means  of  an  independent  one.  If  the  latter  plan  be 
adopted,  make  an  incision  in  the  long  axis  of  the  axilla  just  in  front 
of  the  axillary  border  of  the  scapula  through  the  integument  and  fas- 
cia, then  with  the  lingers  and  the  handle  of  the  scalpel  cautiously  dis- 
connect and  remove  the  areolar  tissue  and  glands.  The  large  veins 
must  be  carefully  avoided,  not  so  much  on  account  of  the  hemorrhage 
that  may  result  if  they  be  injured,  as  from  the  danger  of  the  entrance 
of  air,  due  to  the  respiratory  action.  When  the  removal  is  completed, 
wash  the  space  thoroughly  with  an  antiseptic  solution,  introduce 
drainage-tubes,  bring  the  arm  to  the  side  of  the  chest,  and  dress  anti- 
septically.  Keep  the  patient  quiet,  so  that  union  by  first  intention 
may  be  secured  if  possible  ;  for,  if  the  wound  heals  by  granulation, 
there  is  danger  of  obstruction  of  the  circulation,  and  crippling  of  the 
movement-  of  the  arm  from  cicatricial  contraction. 

If  it  be  found  to  be  impossible  to  remove  the  malignant  growths 
from  around  the  vessels,  the  question  of  amputation  at  the  shoulder- 
joint  is  to  be  taken  into  consideration. 

Extirpation  of  the  Parotid  Gland. — The  complete  removal  of  this 
gland  i-  one  of  tin-  most  dillicult  operations  in  surgery,  especially 
when  it-  relation-  are  changed  by  a  morbid  malignant  growth,  impli- 
cit* structure. 

Contiguous  Anatomy. — The  -pace  in  which  this  gland  is  located  is 
deep,  narrow  above,  broader  below,  and  modified  bj  the  movement  of 
the  lower  jaw.     It  is  bounded  above  by  the  zygoma;  below,  by  a  line 

tiding    from    the   angle-   of   the    inferior   maxilla  backward    to  the 

-:    .     '.'1  mil  cle  ;  in  front,  by  the  posterior  border  of  the  ramus 
81 


482  OPERATIVE   SURGERY. 

of  the  jaw  ;  behind,  by  the  external  auditory  meatus  and  mastoid  pro- 
cess. The  gland  is  separated  from  the  submaxillary  region  by  the 
stylo-maxillary  ligament,  and  from  the  deeper  tissues  by  the  styloid 
process,  and  the  ligaments  and  muscles  connected  with  it.  Prolonga- 
tions of  considerable  size  extend  from  its  deep  surface  inward,  one  in 
front  and  the  other  behind  the  styloid  process,  the  former  passing  be- 
hind the  mastoid  process  and  sterno-mastoid  muscle,  the  latter  to  the 
back  part  of  the  glenoid  fossa.  The  external  carotid  artery  passes 
through  the  gland  from  below  upward,  dividing  into  its  terminal 
branches  before  its  escape.  Superficial  to  this  artery  there  is  a  venous 
trunk  formed  by  the  union  of  the  temporal  and  internal  maxillary 
veins  ;  to  this  trunk  the  internal  jugular  is  connected  by  a  small 
branch  that  passes  through  the  gland  structure.  The  facial  nerve  and 
its  branches  traverse  the  gland  from  behind  forward  and  receive  a 
communicating  branch  from  the  great  auricular  in  its  substance.  Im- 
mediately beneath  the  floor  of  the  space  lie  the  internal  carotid  artery 
and  internal  jugular  vein,  along  with  the  spinal  accessory,  glossopha- 
ryngeal, and  pneumogastric  nerves.  Lymphatic  glands  lie  over  the 
parotid,  and  their  enlargement  may  be  mistaken  for  that  of  the  gland 
itself. 

Contraindications  to  Extirpation :  immobility  of  the  tumor,  and 
a  malignant  growth  implicating  the  structure  of  the  gland. 

Operation. — Place  the  patient  upon  a  suitable  table,  in  a  good 
light,  with  the  shoulders  elevated  and  the  head  turned  to  the  opposite 
side.  Make  an  incision  from  the  zygoma  along  the  central  line  of  the 
tumor  to  its  lower  border.  If  necessary,  this  one  can  be  supplemented 
by  one  or  more  extending  from  it  at  right  angles.  The  integument- 
ary flaps  are  freely  reflected  to  expose  the  growth.  The  tumor  should 
be  raised  from  below  upward,  and  held  by  a  volsella.  This  will  raise 
the  external  carotid  from  its  bed,  when  it  must  be  isolated  and  tied 
between  two  ligatures.  The  vessels  that  enter  or  escape  from  the  tu- 
mor at  this  point  should  be  treated  in  the  same  manner.  The  tumor 
can  now  be  raised  upward,  and  its  separation  from  the  deeper  tissues 
continued  by  means  of  the  fingers  or  handle  of  the  scalpel ;  the  former 
are  the  better. 

The  separation  of  the  growth  from  the  floor  of  the  space  must  be 
done  gently  and  with  great  caution,  on  account  of  the  contiguity  of 
the  internal  jugular  vein  and  the  other  important  vessels,  and  the 
nerves  located  there,  which,  if  the  growth  be  a  large  one,  will  be 
pressed  upon  by  it,  and  may  become  adherent  to  it.  It  is  scarcely 
possible  to  avoid  division  of  the  facial  nerves  if  the  growth  be  com- 
pact. If  it  be  soft  and  spongy,  the  integrity  of  the  nerve  may  be  pre- 
served by  a  careful  use  of  the  fingers  or  director.  The  upper  extrem- 
ity of  the  gland  is  last  removed.  This  step  of  the  operation  is  neces- 
sarily attended  with  considerable  hemorrhage,  which  is,  however,  easily 


MISCELLANEOUS   OPERATIONS.  483 

controlled.  After  the  removal,  unite  the  flaps,  establish  drainage,  and 
dress  autiseptically. 

Fault*. — This  operation  has  been  done  upward  of  one  hundred 
and  ten  times.  When  done  for  malignant  growths,  the  disease  has 
almost  invariably  returned  within  six  months.  The  dangers  to  life 
from  the  operation  itself,  when  carefully  performed,  are  not  imminent. 

Paracentesis  Thoracis. — This  operation  is  done  to  remove  a  fluid 
accumulation  from  the  chest  cavity. 

The  instruments  employed  for  the  purpose  should  be  one  of  the 
many  forms  of  aspirators  (Figs.  580,  581).  If  one  of  these  be  not 
available,  the  ordinary  trocar  and  canula  can  be  used,  due  heed  being 
given  to  the  danger  of  the  admission  of  air  into  the  pleural  cavity. 
The  intercostal  space  through  which  the  trocar  should  be  introduced 
will  depend  upon  the  amount  of  fluid  in  the  cavity.  As  a  rule  it  may 
be  stated  that  the  intercostal  space  selected  should  be  three  or  four 
inches  above  the  lowest  limit  of  abnormal  dullness.  The  instrument  is 
introduced  nearest  to  the  upper  border  of  the  rib,  midway  between  its 
sternal  and  vertebral  extremities,  or  on  a  line  with  the  inferior  angle 
of  the  scapula.  It  is  often  very  difficult,  on  account  of  obesity,  to 
determine  the  numerical  relations  of  the  ribs.  The  elevation  between 
the  first  and  second  bones  of  the  sternum  corresponds  exactly  to  the 
articulation  of  the  second  costal  cartilages.  The  nipple  in  the  male 
is  located  usually  between  the  fourth  and  fifth  ribs.  If  the  nipple  be 
normally  located,  a  line  carried  horizontally  from  it  around  the  chest 
will  pass  over  the  sixth  intercostal  space  in  the  line  of  the  axilla  ;  if 
the  arm  be  raised,  the  first  visible  digitation  of  the  serratus  magnus 
is  attached  to  the  sixth  rib.  The  inferior  angle  of  the  scapula  covers 
the  seventh  rib,  therefore  the  first  intercostal  space  below  it  is  the 
seventh.  The  eleventh  and  twelfth  ribs  can  be  felt  in  corpulent  per- 
sons outside  the  erector  spinae,  sloping  downward.  If  any  one  of  the 
intercostal  spaces  below  the  seventh  be  selected,  the  diaphragm  may 
be  punctured  if  the  trocar  be  inserted  incautiously. 

Operation. — Prop  up  the  patient  in  bed,  or,  if  able,  allow  him  to 
sit  astride  a  chair  with  his  arms  resting  on  its  back,  and  his  head  sup- 
ported by  them.  The  thickness  of  the-  walls  of  the  chest  and  the 
presence  of  fluid  must  first  be  determined  by  the  introduction  of  the 
needle  of  a  hypodermic  syringe.  All  the  instruments  and  the  surface 
at  the  point  of  proposed  puncture  should  be  well  carbolized.  The 
integument  over  the  intercostal  space  through  which  the  puncture  is 
to  be  made  must  be  drawn  upward,  since,  as  the  fluid  escapes  from 
the  chest,  the  space  will  descend  :  if  this  be  not  done,  the  puncture 
through  the  skin  will  soon  be  above  the  intercostal  space.  A  knowl- 
edge  of  this  bet  is  of  immense  importance  if  a  permanent  opening 
be  established,  as  in  empyema.  If  the  puncture  be  made  in  the 
vicinity  of  the  diaphragm,  the  point  of  the  instrument  must  be  di- 


484 


OPERATIVE   SURGERY. 


rected  upward  and  inward.  Locate  the  seat  of  the  proposed  puncture 
and  make  a  small  incision  through  the  skin  with  a  lance,  with  or  with- 
out the  use  of  cocaine,  insert  the  end  of  the  instrument,  and  as  soon 
as  the  point  is  fully  engaged  in  the  tissues,  extract  the  air  if  it  be 
connected  with  an  aspirator,  and  push  it  quickly  in,  guarded  by  the 
index-finger  laid  along  its  side.  If  the  instrument  become  closed  by 
false  membrane  or  floating  fibrin,  the  obstruction  must  be  removed  by 
a  small  wire  passed  through  its  lumen.  The  pulse  and  the  sensations 
of  the  patient  must  be  consulted  during  the  evacuation  to  avoid,  if 
possible,  sudden  syncope.  Death  is  rarely  directly  due  to  this  oper- 
ation. 

Perforation  of  the  Antrum. — When  fluid  accumulations  occur  in 
this  cavity,  they  can  be  removed  by  the  trephine,  or  by  the  ordinary 
bone-drill  passed  into  it  through  its  anterior  wall,  or  into  its  floor 
through  the  socket  of  the  first  permanent  molar  tooth,  being  careful 
that  the  drill  does  not  perforate  the  floor  of  the  orbit.  The  cavity  is 
then  washed  out  and  the  opening  maintained  by  the  introduction  of 
a  gold  tube,  if  practicable,  until  the  function  of  the  mucous  membrane 
is  restored. 

OPERATIONS   UPON   THE   NOSE. 

Plugging  the  Posterior  Nares  (Fig.  756). — This  is  done  to  arrest 
obstinate  epistaxis.     The  tampon  or  plug  can  be  made  of  sponge,  lint, 


Fig.  756. — Plugging  posterior  nares. 


Fig.  757. — Bellocq's  canula. 


or  of  suitable  cloth,  and  should  be  of  a  proper  size  to  closely  fit  the 
posterior  naris,  which  in  the  adult  is  about  three  fourths  of  an  inch 
long  and  half  an  inch  wide.  The  plug  is  made  by  tying  a  strong 
ligature  around  the  middle  of  the  material  selected  for  the  purpose 
and  suitably  arranged,  cutting  the  ends  of  the  ligature  short,  and  pass- 
ing beneath  it  on  opposite  sides  of  the  plug  two  equally  strong  liga- 


MISCELLANEOUS   OPERATIONS. 


485 


tores,  which  are  looped  around  and  firmly  tied  to  the  first  one.  The 
canula  of  Bellocq  (Fig.  757),  with  the  spring  withdrawn,  is  then  car- 
ried along  the  floor  of  the  nostril  to  the  posterior  wall  of  the  pharynx, 
when  the  movable  rod  is  projected  and  curves  forward  into  the  mouth. 
The  extremities  of  the  loop  at  one  side  of  the  tampon  are  passed 
through  the  instrument  and  down  through  the  meatus  by  returning 
the  central  rod  and  withdrawing  the  instrument.  The  tampon  is 
now  carried  into  position  by  pulling  upon  the  strings  aided  by  the 
finger  carried  behind  the  soft  palate.  Sufficient  traction  is  made 
upon  it  to  forcibly  close  the  naris,  and  the  strings  in  front  are  tied 
around  a  plug  of  a  similar  material,  which  closes  the  anterior  open- 
ing. The  plug  should  be  well  carbolized  before  its  introduction, 
and,  if  need  be,  can  be  wet  with  astringent  solutions.  It  should  be 
removed  at  the  end  of  forty-eight  hours,  which  can  be  easily  done  by 
pulling  on  the  strings  remaining  in  the  mouth  while  it  is  forced  back- 
ward by  an  instrument  introduced  through  the  floor  of  the  nostril. 
If  the  canula  of  Bellocq  be  not  available, 
a  long,  flexible  probe,  an  ordinary  gum 
catheter,  and  even  common  wire,  may  be 
utilized.  Sometimes  a  string  is  carried 
through  the  nostril  by  means  of  the  can- 
ula and  attached  to  the  plug,  instead  of 
being  tied  to  it  before  the  canula  is  in- 
troduced. 

Removal  of  Nasal  Polypi.  —  If  the 
growths  or  pedicles  be  small,  they  can  be 
quite  readily  removed  by  forceps  (Figs. 
758  and  759)  or  the  snare.  If  the  forceps 
are  to  be  employed,  the  patient  should  sit 
in  a  chair,  exposed  to  a  strong  light,  with 
the  head  supported  by  an  assistant,  and, 
after  spraying  the  nares  with  a  strong 
solution  of  cocaine,  the  attachment  of  the 
growth  is  seized,  and  it  is  twisted  off  by 
turning  the  instrument  several  times  on 
itfl  lung  axis.  If  the  growth  be  attached 
to  a  turbinated  bone,  it  may  be  necessary 

to  jiull  away  some  of  the  bone  structure  before  the  tumor  can  be  re- 
moved.    If  the  growth  be  situated  far  back  or  hang  down  into  the 


Fig.  T58. — Curved  Fig.  759.— 
nasal  polypus  for-  Straight  na- 
ccps.  sal  polypus 

forceps. 


Via.  700. — Nasal  polypus  canula. 


486 


OPERATIVE   SURGERY. 


fauces,  it  may  be  detached  by  the  finger  passed  behind  the  soft  palate. 
If  this  fail,  it  may  be  snared  (Figs.  761,  762,  763).      The  wire,  either 


Fig.  761.— Sexton's 
snare. 


Fig.  762.— Codman  &  Shurt- 
lcff's  snare. 


Fig.  763. — Jarvis' 
polypus  snare. 


with  or  without  the  canula,  is  passed  along  the  floor  of  the  nose, 
and  the  loop  passed  over  the  tumor  (Fig.  764),  by  aid  of  the  finger 


Fig.  764. — Removing  polypus. 

if  necessary  ;  the  loop  is  tightened  and  the  growth  severed  (Fig.  765). 
If  the  growth  be  fibrous  and  not  accessible  by  the  previously  men- 
tioned methods,  it  can  then  be  exposed  by  opening  the  nasal  cavity. 


MISCELLANEOUS   OPERATIONS. 


487 


Fig.  765. — Double  canula  in  position. 


The  cavity  of  the  nose  may  be  exposed  if  the  nose  be  turned  upward 
after  detaching  it  on  both  sides  through  the  alae  and  at  the  junction  of 
the    nasal    bones   with   the 
nasal  processes  of  the  supe- 
rior   maxilla?,  and   in    the 
median  line  to  the  septum. 
After  the   removal   of   the 
growth   the    parts    are    re- 
stored to  their  normal  po- 
sition, and  the  edges  of  the 
wound     united.       If    this 
method  be  not  deemed  ad- 
visable,   the    nose    can    be 
turned  downward  by  mak- 
ing   a    U-shaped    incision 

down  to  the  bone,  the  convex  portion  of  which  shall  cross  the  root  of 
the  nose  between  the  eyes  and  extend  downward  at  each  side  of  the 

nose  to  the  outer  borders  of  the 
alae  (Fig.  766,  a).  The  bones  are 
then  sawn  through  in  the  line  of 
the  incision,  the  septum  liberated 
at  their  under  surface,  and  the 
nose  turned  downward,  so  as  to 
expose  the  interior  surfaces  to  ob- 
servation and  manipulation.  If 
the  growth  be  a  large  one  and 
greater  space  be  necessary,  the 
incision  can  be  modified,  as  shown 
by  the  dotted  line  b,  and  the 
bones  lying  in  their  course  sawn 
through  as  before  described,  care 
being  taken  to  avoid  the  roots  of 
the  teeth.  After  the  removal  of 
the  growth  the  parts  are  replaced 
and  confined  in  position  by  su- 
tures, dressings,  etc.  Nasopha- 
ryngeal polypi  can  sometimes  be 
removed  by  this  method  (Oilier). 
Langeribectfa  Method. — Make  an  incision  from  the  junction  of  the 
nasal  with  the  frontal  bone  vertically  downward  in  the  median  line  of 
the  nose  to  the  tipper  border  cf  the  cartilages  of  the  alas,  thence 
(Hit ward  upon  the  cheek  (Fig.  767,  a).  Dissect  off  the  triangular 
flap,  leaving  the  periosteum  ;  sever  the  alar  cartilage  from  the  nasal 
bone,  and  with  bone  nippers  sever  the  nasal  bone  from  its  fellow. 
Aloo  in  the  same  manner  separate  the  nasal  process  of  the  superior 


FlO.  7G6. — Lines  of  incision. 


488 


OPERATIVE   SURGERY. 


Fig.  767. — Langenbeck's  lines  of  incision. 


maxilla  from  its  body,  then  the  entire  upper  part  of  the  nasal  cavity 
can  be  exposed  by  raising  upward  the  quadrilateral  plate  of  bone. 

After  the  tumor  is  re- 
moved, the  bone  can 
be  returned  and  fast- 
ened in  its  proper 
position.  If  the  tu- 
mor be  still  larger,  it 
may  be  attacked  by 
an  opening  through 
the  hard  palate  (Ne- 
laton,  Fig.  768). 

NelatorCs  Method 
(Fig.  768).— Make  an 
incision  in  the  medi- 
an line,  through  the 
soft  palate  down  to 
the  bone  ;  continue 
it  forward,  along  the 
posterior  half  of  the 
hard  palate  ;  two  oth- 
ers are  now  carried  obliquely  outward  on  either  side  from  the  anterior 
extremity  of  the  incision  along  the  hard  palate,  to  the  alveolar  pro- 
cess ;  these  flaps,  including  the  periosteum,  are  reflected  outward,  the 
hard  palate  perforated  and  cut  away,  the  periosteum  and  mucous 
membrane  of  the  floor  of  the  nose  turned  aside,  the  septum  removed 
if  necessary,  and  the  tumor  will  be  exposed 
to  view  and  can  be  removed.  The  periosteal 
flap  of  the  hard  palate  should  be  returned  to 
the  normal  position,  and  stitched  after  the 
growth  is  removed.  The  cut  through  the 
soft  palate  can  be  joined  subsequently.  If 
the  growth  be  a  small  one,  but  one  side  of 
the  hard  palate  need  be  attacked.  Naso- 
pharyngeal polypi  may  be  advantageously 
reached  by  this  method. 

Removal  of  Naso-Pharyngeal  ■  Polypi. — 
LangenbecFs  Method.  —  Make  a  slightly 
curved  incision  with  the  convexity  down- 
ward, extending  from  the  ala  of  the  nose  to 
the  malar  bone  and  as  far  backward  as  the 
middle  of  the  zygoma.     A  second  incision  is 

made,  beginning  near  to  the  center  of  the  root  of  the  nose,  and,  pass- 
ing along  the  inferior  margin  of  the  orbit,  it  joins  the  former  near  the 
middle  of  the  malar  bone  (Fig.  767,  b).     These  incisions  should  extend 


Fig.  768. — Nekton's  method. 


MISCELLANEOUS   OPERATIONS.  489 

through  the  periosteum  down  to  the  bone  ;  the  soft  parts,  however,  are 
not  to  be  raised.  Separate  the  masseter  muscle  from  the  malar  bone, 
divide  the  buccal  fascia,  depress  the  inferior  maxilla,  and  pass  the  fin- 
ger, if  possible,  into  the  posterior  nares  by  carrying  it  through  the  ptery- 
go-maxillary  fissure  into  the  spheno-maxillary  fossa,  thence  through 
the  spheno-palatine  foramen,  all  of  which  passages  may  have  been  dis- 
tended by  the  morbid  growth.  A  small  key-hole  saw  is  passed  by  the 
same  route,  and  the  superior  maxilla  divided  from  behind  forward  ; 
the  extremity  of  the  saw  is  covered  by  the  end  of  the  index-finger,  car- 
ried into  the  pharynx  through  the  mouth,  to  protect  the  tissues  from 
being  injured  by  it.  The  zygomatic  process  of  the  temporal,  frontal 
process  of  the  malar,  and  orbital  process  of  the  superior  maxilla  are 
sawn  through  to  the  lachrymal  bone.  The  superior  maxilla  can  be 
divided  in  the  line  of  the  superior  incision  of  the  soft  parts,  thus  leav- 
ing the  orbital  process  intact.  The  osteo-cutaneous  flap  is  now  raised 
by  an  elevator  carried  beneath  the  malar  bone  and  slowly  lifted  upward 
and  inward  toward  the  nose,  the  bones  and  soft  parts  of  which  form 
a  hinge  to  the  flap  at  that  side.  If  the  saw  can  not  be  passed  into 
the  posterior  nasal  cavity  even  by  the  aid  of  a  grooved  director, 
the  lips  of  the  incision  of  the  soft  parts  may  be  drawn  asunder 
and  the  bone  sawn  from  without  inward  and  before  backward. 
Either  incision  exposes  polypoid  growths  of  the  pharynx  admirably 
for  manipulation.  The  operation  is  usually  attended  by  quite  se- 
vere hemorrhage,  which,  however,  can  be  controlled  readily  by  press- 
ure and  an  occasional  ligature.  After  the  removal  of  the  growth, 
the  parts  are  adjusted  and  confined  in  position  by  sutures,  etc.  If  the 
growth  to  be  removed  be  a  large  and  va  cular  one,  a  preliminary  tra- 
cheotomy should  be  done.  If  it  be  malignant  and  very  vascular,  and 
have  a  large  attachment,  I  deem  it  a  wise  precaution  to  tie  both  exter- 
nal carotids  prior  to  removal.  The  dangers  from  hemorrhage  will  be 
lessened  by  this  measure,  and,  moreover,  the  diminished  vascularity 
of  the  parts  will  hinder  the  redevelopment  of  the  growth. 

Results. — The  rate  of  mortality  from  this  method  is  less  than 
twenty-five  per  cent,  and  depends  more  on  the  removal  of  the  growth 
than  upon  the  steps  necessary  to  reach  it.  The  mortality  is  greater 
when  the  operation  is  done  through  the  hard  palate  than  when  per- 
formed by  means  of  the  displacement  of  the  upper  jaw. 

Cheever}8  Mil  hod. — In  this  both  superior  maxillae  were  removed, 
owing  to  the  large  size  and  central  situation  of  the  growth.  He  made 
an  incision  from  near  the  inner  canthus  on  each  side  of  the  nose  down- 
ward along  the  natural  furrow,  around  the  alae  to  the  median  line  of 
the  lip,  which  he  divided.  These  flaps  were  reflected  upward  and 
outward  a-  fur  a-  the  rualar  prominence,  and  the  body  of  each  supe- 
rior maxilla  was  sawn  from  behind  forward  to  the  middle  meatus  of 
the  no-*-  :  the  septum  and  vomer  were  cut  with  scissors  ;  the  jaws  were 


490  OPERATIVE   SURGERY. 

then  depressed  and  the  tumor  removed  ;  after  which  the  bones  were 
replaced  and  wired  in  position.  The  loss  of  blood  was  not  great,  but 
the  patient  died  on  the  fifth  day  from  exhaustion. 

The  excision  of  the  entire  upper  jaw  may  be  practiced  for  the  re- 
moval of  these  growths,  or  only  the  portion  below  the  line  of  the 
orbital  floor  may  be  removed.  The  superior  maxilla  can  be  raised 
and  turned  outward  on  a  hinge  formed  by  the  zygomatic  process  of 
the  malar  bone  and  the  contiguous  soft  parts,  by  dividing  the  bone 
in  the  line  of  Ferguson's  incision  (Fig.  243,  h),  the  upper  portion 
of  which,  for  this  purpose,  should  be  extended  to  the  malar  bone. 
The  maxillae  are  separated  by  sawing  through  the  hard  palate  and 
alveolar  process,  and  the  nasal  bone  is  disconnected  from  the  superior 
maxilla  by  severing  its  connections  with  bone-forceps.  The  osteo- 
cutaneous flap  can  then  be  raised  and  swung  outward.  If  necessary, 
the  soft  palate  may  be  divided.  After  the  removal  of  the  growths 
the  parts,  including  the  soft  palate,  are  adjusted  and  joined  by  su- 
tures. 

With  the  view  of  avoiding  as  far  as  possible  the  division  of  the  ter- 
minal filaments  of  the  superior  dental  nerve,  and  obviating  the  loss  of 
function  incident  thereto,  Langenbeck  recommended  that  a  curved 
incision  be  made,  crossing  the  cheek  about  midway  between  the  angle 
of  the  mouth  and  the  lower  border  of  the  orbit,  beginning  near  the 
lower  end  of  the  nasal  bone  and  extending  downward,  outward,  and 
upward  so  as  to  avoid  the  Stenon  duct.  The  flaps  are  dissected  from 
the  superior  maxilla  and  it  is  removed  through  the  opening  made 
in  the  soft  parts.  If  the  whole  bone  is  to  be  removed,  the  integ- 
rity of  the  superior  maxillary  nerve  can  be  still  further  preserved  by 
removing  it  from  the  infra-orbital  groove  by  the  aid  of  a  fine,  sharp 
chisel. 

The  removal  of  a  growth  of  any  great  size  from  the  posterior  nares 
or  pharynx,  especially  the  latter,  will  be  attended,  if  its  attachment 
be  extensive,  by  the  entrance  of  a  large  amount  of  blood  into  the 
pharynx  and  trachea  ;  it  is,  therefore,  wise  to  do  a  preliminary  trache- 
otomy so  that  the  lower  extremity  of  the  pharynx  may  be  closed  by 
sponges,  or  otherwise  tamponed.  If  the  shoulders  be  elevated  and 
the  head  allowed  to  fall  far  backward,  the  blood  can  be  removed  from 
the  dependent  portion  of  the  pharynx  as  fast  as  it  collects ;  this  posi- 
tion, however,  impedes  respiration  by  over-extending  the  muscles  that 
act  on  the  os  hyoides.  If  a  preliminary  tracheotomy  be  done,  the 
anaesthetic  must  be  administered  through  the  tube.  The  apparatus 
devised  for  this  purpose  by  Trendelenburg  (Fig.  769)  may  be  used 
entire,  or  only  the  inhaling  portion  attached  to  the  ordinary  trache- 
otomy-tube can  be  employed ;  the  latter  plan  is  generally  to  be  pre- 
ferred, since  the  rubber  tampon  attached  to  this  tube  often  causes 
bronchial  irritation  when  inflated  ;  moreover,  if  it  become  ruptured 


MISCELLANEOUS   OPERATION'S. 


491 


during  the  course  of  an  operation,  or  be  imperfectly  distended,  blood 
may  enter  the  trachea  unawares. 


Fig.  769. — Trendelenburg's  trachea  tampon. 

Deviation  of  the  Septum  Nasi. — It  not  unfrequently  occurs  that  both 
the  bony  and  cartilaginous  portions  of  the  septum  are  deflected  to 
such  an  extent  as  to  seriously  interfere  with  breathing  through  the  nose 
during  attacks  of  coryza,  and  likewise  impart  a  distinct  nasal  twang 
to  the  voice.  This  deformity  may  or  may  not  be  associated  with  ex- 
ternal modifications  of  the  nasal  symmetry.  In  either  case  the  indi- 
cation remains  the  same — to  overcome  the  deformity  and  to  maintain 
the  corrected  relations  of  the  parts  until  recovery  takes  place. 

Operation, — The  deformity  can  be  overcome  by  grasping  the  ab- 
normal septum  between  the  blades  of  forceps  especially  designed  for 
the  purpose  (Fig.  770),  which  are  thrust  into  the  anterior  nares  and 
closed  upon  the  de- 
formed septum,  and 
held  for  a  few  mo- 
ments    with    suffi- 
cient    firmness    to 
press  its  irregulari- 
ties into  a  normal 
position.      The  re- 
sistance is  still  fur- 

fcher  overcome  by  cautiously  turning  the  forceps  from  side  to  side  on 
their  long  axis.  The  pressure  exerts  a  crushing  and  compressing  in- 
fluence "n  the  septum,  causing  it  to  assume  or  admit  of  its  being 
pressed  into  a  normal  position.     The  retentive  apparatus  is  a  specially 

itracted   clamp  (Fig.  771),  which  is  screwed    info   position  while 

ping  the  septum.  The  instrument  retains  the  parts  thus  rectified 
until  the  reparative  processes  necessary  to  their  permanency  shall 
take  place.  The  clamp  fan  !><■  permitted  to  remain  in  position 
or  three  days,  not  tightly  screwed — for  this  would  cause  ulcera- 
tion— but  closely  enough  to  exert  a  gradual  controlling  influence. 
This    indication    fan    likewise    be    w<ll    met    by    introducing   rubber 


Fig.  770. — Adams'  rhinoplastos  forceps. 


492 


OPERATIVE   SURGERY. 


Fig.   771. — Adams' 
clamps. 


Fig.  772. — Ivory 
plugs. 


tubes  of  proper  size  and  length,  surrounded  by  oiled  lint,  into 
each  nostril ;  these  tubes  by  their  elastic  pressure  answer  the  pur- 
poses of  the  clamp,  and  at  the  same  time  permit  air  to  pass  unob- 
structed through  the  nostrils. 
After  three  or  four  days  either 
of  the  preceding  appliances 
should  be  replaced  by  ivory 
plugs  (Fig.  772),  which  are 
pushed  into  each  nostril  and 
worn  at  night  only.  It  is  true 
that  this  treatment  is  annoying 
and  even  attended  by  positive 
discomfort,  yet  the  almost  as- 
sured good  result  will  amply  re- 
pay the  patient  for  the  affliction 
incurred.  In  addition  to  this, 
other  operations  are  recom- 
mended, such  as  the  removal  of 
the  inferior  turbinated  bone  on 
the  side  of  the  deflection  ;  punching  the  septum,  to  establish  a  com- 
munication between  the  closed  and  the  unclosed  nostril.  Neither 
of  these  rectify  the  deformity,  and  both  are  open  to  objections,  the 
former  of  a  physiological,  the  latter  of  a  pathological  nature.  The 
removal  of  the  projecting  cartilage  and  its  mucous  membrane  is  like- 
wise commended.  The  removal  of  the  deformed  septum  together 
with  a  portion  of  the  superior  maxilla  (Post),  accomplished  by  sepa- 
rating the  side  of  the  nose  from  the  cheek,  turning  the  nose  over, 
and  thus  gaining  access  to  the  obstruction,  constitutes  an  opera- 
tion having  a  severity  out  of  proportion  to  that  of  the  primary  diffi- 
culty ;  and,  moreover,  it  may  be  followed  by  an  unsightly  scar.  It 
is  recommended  that  the  meatus  be  burred  out  (Wagner)  by  means  of 
the  dental  engine.  The  results  which  he  reports  certainly  give  strong 
testimony  in  favor  of  the  suggestion.  The  deformed  portion  of  the 
septum  may  be  sawn  off  on  a  plane  conforming  to  that  of  the  remain- 
ing portion  by  first  applying  a  strong  solution  of  cocaine  to  it,  then 
removing  the  deformity  with  a  narrow  fine  saw  constructed  especially 
for  the  purpose.  This  plan  is  followed  by  Professor  Bosworth,  and 
it  appears  to  me  preferable  to  burring  or  punching  the  septum. 

BRONCHOTOMY. 

This  expression  includes  three  distinct  operations — laryngotomy, 
tracheotomy,  and  laryngo-tracheotomy,  the  first  two  of  which  are  still 
further  classified.  These  operations  are  comparatively  easy  in  the 
adult,  especially  if  the  neck  be  long  and  the  landmarks  well  devel- 
oped.    In  the  infant  and  the  child,  and  before  puberty — the  periods 


MISCELLANEOUS   OPERATIONS. 


493 


of  life  when  they  are  most  demanded — the  performance  is  most  diffi- 
cult, owing  to  the  shortness  of  the  neck,  obesity  of  the  patient,  and 
the  rudimentary  condition  of  the  land- 
marks. The  thyroid  cartilage,  which 
is  well  marked  in  the  adult,  constitut- 
ing a  prominent  point  of  reckoning,  is 
scarcely  discernible  in  the  child,  and 
in  the  infant  it  is  impracticable  to  de- 
termine its  location  by  physical  exami- 
nation. The  cricoid  cartilage  is  a  far 
better  guide  by  which  to  determine  the 
comparative  relations  of  the  parts.  It 
is  the  distinctive  cartilage  of  the  laryn- 
geal group,  and,  irrespective  of  age,  it 
can  be  felt  as  a  firm,  round  ring,  much 
more  prominent  than  the  cartilaginous 
rings  of  the  trachea,  which  lie  imme- 
diately below  it.  The  crico-thyroid 
space,  through  which  in  laryngotomy 
the  deep  incision  is  made,  is  located 
immediately  above  the  cricoid  carti- 
lage, between  it  and  the  thyroid  (Fig. 
773).  It  is  situated  at  the  bottom  of 
the  first  groove-like  depression  above 
the  cricoid  cartilage.  The  crico-thy- 
roid membrane  is  composed  of  yellow 

elastic  tissue,  and  is,  therefore,  of  a  yellowish  appearance,  and  is  often 
dotted  by  openings  for  small  vessels.  When  incised  it  will  retract, 
owing  to  its  resilient  nature  ;  hence  all  hemorrhage  should  be 
stopped  before  it  is  opened — if  the  urgency  of  the  case  will  per- 
mit. It  is  not  difficult  to  locate  the  guides  in  the  dead  subject 
under  ordinary  circumstances  ;  but,  in  the  living,  when  they  are  be- 
ing jerked  upward  and  downward  by  the  efforts  at  respiration,  it  is 
a  matter  of  great  difficulty,  and  may  be  impossible.  The  only  artery 
normally  in  the  line  of  the  operation  of  laryngotomy  that  need  be  re- 
spected is  the  crico-thyroid,  which  runs  along  the  upper  border  of  the 
space,  testing  on  the  membrane  of  the  same  name.  It  is  troublesome, 
not  from  the  amount  of  blood  it  contains,  but  from  its  relation  to  the 
opening  in  the  membrane,  through  which  a  small  amount  of  blood 
may  pass  into  the  tube.  The  vessels  causing  the  greater  annoyance 
— especially  if  the  patient  be  much  cyanosed— are  the  small  venous 
trunks  which  run  across  the  tracheal  and  laryngeal  region,  without  any 
definitely  established  relationship,  and  which  return  their  blood  chiefly 
into  tin-  superior  thyroid  veins  (Pig.  774).  The  anterior  jugular  veins 
will  be  troublesome,  unless  the  median  line  be  adhered   to  closely.     It 


Fig.  7*73.  —External  cartilages  of  the 
larynx,  a.  Kody  of  hyoid  bone.  b. 
Thyroid-hyoid  membrane.  c.  Thy- 
roid cartilage.  d.  Crico-thyroid 
membrane,  e.  Cricoid  cartilage,  f. 
First  tracheal  ring.  g.  Isthmus  of 
thyroid  body. 


494 


OPERATIVE   SURGERY. 


is  unnecessary,  I  trust,  to  allude  to  the  well-known  relation  between 
the  larynx  and  the  large  vessels  of  the  neck.     The  thymus  gland  in 


Fig.  774. — Surgical  anatomy  of  larynx  and  trachea,  a.  Thyroid  cartilage,  b.  Crico-thyroid 
membrane  and  artery,  c.  Cricoid  cartilage,  d.  Superior  thyroid  vein.  e.  Inferior  thy- 
roid vein.     f.  Arteria  innominata.     h.  Thyroid  body. 

the  very  young  deserves  respectful  consideration,  as  will  hereafter 
appear.  The  choice  of  anaesthetics  to  be  given  in  operations  where 
the  respiratory  function  of  the  larynx  is  involved  is  a  matter  entitled 
to  some  consideration.  For  instance,  if  ether  be  given  to  one  who 
has  no  laryngeal  irritation  or  obstruction,  the  frequent  spasm  of  those 
parts  is  familiar  to  all.  If  to  this  be  now  added  the  deficient  aeration 
of  the  blood,  due  to  a  laryngeal  obstruction,  together  with  the  in- 
creased tendency  to  spasm,  dependent  on  laryngeal  disease,  then  is 
the  danger  of  asphyxia  greatly  augmented.  Chloroform  may  be  given 
with  but  little  danger  of  causing  spasm  ;  if  ether  be  administered,  it 
must  be  commenced  very  gradually,  to  avoid  as  much  as  possible  the 
occurrence  of  laryngeal  spasms.  In  many  instances  the  pressing  na- 
ture of  the  case  will  not  permit  the  expenditure  of  the  time  necessary 
to  produce  anaesthesia.  In  those  cases  presenting  marked  cyanosis 
the  sense  of  pain  is  much  blunted,  and  the  operation  should  be  done 
without  an&ssthesia.  The  instruments  suitable  for  these  operations 
are  quite  numerous,  yet  the  absence  of  any  one  or  more  of  them  is 
not  to  be  considered  a  reason  for  its  non -performance  when  demanded. 
When  necessary,  a  pocket-knife,  a  hair-pin,  or  a  toothpick,  can  be 
extemporized  to  advantage,  thus  preventing  the  death  of  the  patient 
unaided  because  a  tracheotomy-tube  is  not  obtainable. 


MISCELLANEOUS   OPERATIONS. 


495 


Tracheotomy  Instruments.— -T 'wo  scalpels  should  be  at  hand,  one 
sharp  and  the  other  probe-pointed  (Fig.  775)  ;  also  an  ordinary  grooved 
director,  retractors  (Figs.  776  and  777),  and  small  spatulas,  to  draw 
aside  the  tissues,  and  tracheotomy-hooks,  to  fix  the  trachea  during  its 


Fig.  775.— 
Probe-pointed 

scalpel. 


Fig.  776.—    Fig.  777.—     Fig.  778.—  Lan- 
Rdtractor.       Tenaculum-       genbeck's  dou- 
retraetor.         ble  hook. 


Fig.  779. — Trousseau's 
trachea  dilator. 


incision  (Fig.  778).    The  hook  illustrated  is  the  best  in  use,  because  the 
line  of  the  cut  can  be  made  between  its  blades,  and  the  center  line  of 


Fig.  780. — Chassaignac's  trachea  dilator. 


496 


OPERATIVE   SURGERY. 


the  trachea  is  therefore  better  assured.  There  are  various  forms  of 
tracheotomes,  which  should  not,  in  my  opinion,  be  substituted  for  the 
sharp-pointed  bistoury,  because  they  are  much  less  surgical  in  their 


Fig.  781. — Silver  trachea  tube. 


Fig.  782. — Ilard  rubber  trachea  tube. 


inception  and  far  more  dangerous  in  their  use.  Dilators,  too,  are  quite 
numerous  and  varied  in  pattern.  Trousseau's  (Fig.  779)  and  Chas- 
saignac's  (Fig.  780)  are  fair  representatives  of  them,  and  will  answer 
the  purpose  admirably.  The  borders  of  the  tracheal  opening  can 
always  be  easily  drawn  apart  by  the  common  tenacula  or  by  two  of  the 
ordinary  grooved  directors  with  aneurism-needle  attachments.  Trache- 
otomy-tubes of  various  forms  are  employed.  Figs.  781  and  782  repre- 
sent those  in  every-day  use,  the 
latter  being  of  hard  rubber. 
The  bivalve  trachea  tube  (Fig. 
783)  is  an  admirable  instru- 
ment, since  it  can  be  introduced 
through  the  opening  in  the 
trachea  much  more  readily  than 
the  ordinary  blunt-ended  pat- 
tern, and  can  be  afterward 
quickly  opened  by  the  introduc- 
tion into  it  of  the  companion 
tube  (Fig.  784).  Fig.  785  repre- 
sents forceps  for  the  removal  of 
foreign  bodies.  A  long  feather, 
with  the  tip  of  the  brush  remaining,  should  be  at  hand  to  insert  into 
the  trachea  through  the  tube,  to  create  the  irritation  sometimes  neces- 
sary to  cause  the  expulsion  of  the  tracheal  mucus.  A  so-called  trachea 
aspirator  has  been  devised  to  remove  mucus  and  blood  from  the  trachea 
(Fig.  786).  It  is  used  as  follows  :  After  the  insertion  of  the  trachea 
tube,  place  the  thumb  on  the  air-hole  of  the  barrel ;  apply  the  soft 
rubber  cup  over  the  tube,  and  withdraw  the  piston,  when  the  mucus 
and  blood  will  enter  the  barrel.  It  has  not  infrequently  happened  that 
a  patient  is  unable  to  expel  the  blood  and  mucus  on  account  of  stupor  or 
weakness,  and  the  lips  of  the  operator  were  used  to  clear  the  trachea. 


Figs.  783,  784. — Bivalve  trachea  tubes. 


MISCELLANEOUS   OPERATIONS. 


497 


This  is  obviously  a  hazardous  procedure,  if  the  patient  have  syphilis 
or  diphtheria.     The  possession  of  the  tracheal  aspirator  will  be  wel- 
comed as  prefera- 
ble under  all  cir- 
cumstances. 

A  serviceable 
instrument  for 
the  purpose  of  re- 
moving blood, 
etc.,     from      the 

trachea-tube,  and  Fig.  "785.— Trachea  forceps. 

even     from     the 

trachea  itself,  can  be  quickly  extemporized  by  attaching  to  the  nozzle 
of  an  ordinary  two-ounce  rubber  syringe  a  soft  piece  of  rubber  tubing 


Fig.  786. — Trachea  aspirator. 

five  or  six  inches  in  length.  The  unattached  end  of  the  rubber  tubing 
is  inserted  into  the  trachea-tube  or  into  the  trachea  itself  ;  the  piston 
of  the  syringe  is  withdrawn  somewhat  quickly,  and  the  fluid  sucked 
up.  If  the  suction  be  made  too  quickly,  the  tube  will  be  collapsed 
and  inoperative.  Large  portions  of  membrane  have  been  drawn  from 
the  bronchial  tubes  in  this  manner. 

Laryngotomy. — Place  the  patient  on  a  table  with  the  shoulders 
elevated,  head  thrown  back,  and  neck  exposed  to  a  strong  light.  At 
least  three  assistants  are  required,  especially  if  an  anaesthetic  be  given. 
Locate  the  cricoid  cartilage,  support  the  larynx  firmly  between  the 
thumb  and  finger  of  the  left  hand,  then  make  an  incision  through  the 
integument  an  inch  and  a  half  in  length  in  the  adult,  terminating  at 
the  lower  border  of  the  cricoid  cartilage,  and  divide  the  fascia  on  a 
director  ;  divide  the  connections  between,  and  separate  the  borders  of 
the  sterno-h  void  muscles  with  retractors,  push  aside  the  veins  and  con- 
nective tissue,  and  the  crico-thyroid  membrane  will  be  seen.  If  the 
case  be  not  urgent,  check  all  haemorrhgc  before  opening  the  larynx. 
If  otherwise,  open  it  at  once,  when  the  entrance  of  air  and  the  resump- 
tion of  the  respiratory  functions  will  dispel  the  cyanosis  and  check  the 
bleeding.  The  larynx  is  seized  and  held  firmly  by  a  tenaculum  while 
the  opening  is  made  through  the  crico-thyroid  membrane  transversely 
along  the  upper  border  of  the  cricoid  cartilage  to  avoid  the  crico-thyroid 
artery,  that  run.-:  along  the  upper  border  of  the  membrane,  near  the  thy- 


498 


OPERATIVE   SURGERY. 


roid  cartilage,  and  also  to  remove  the  tube  as  far  as  possible  from  the 
vocal  cords.  The  whistling  of  the  ingoing  air,  succeeded  by  an  expul- 
sive cough — which  ejects  the  mucus,  blood,  and  other  matters — follow 


Fig.  787. — Opening  the  trachea. 

quickly  after  the  incision.  If  the  operation  be  performed  for  the  re- 
moval of  a  foreign  body,  it  may  at  this  time  be  expelled,  or  become 
lodged  near  the  opening,  when  it  can  be  removed  by  forceps.     If  the 

operation  be  performed  for 
laryngeal  diphtheria,  the  tube 
should  not  be  inserted  until  all 
loose  membrane  has  been  ex- 
pelled, and  such  as  may  be 
within  reach  of  the  forceps  has 
been  pulled  away.  If  blood 
escape  into  the  opening  from 
the  oozing  vessels,  the  pressure 
of  the  tube  upon  the  lips  of  the 
wound  will  serve  to  check  it, 
and  for  this  reason  it  may  be 
introduced  early.  The  tube  is 
carried  carefully  in  while  the 
borders  of  the  opening  are  held 
apart  with  the  orthodox  retract- 
or, or  by  means  of  two  blunt 
artery-needles  or  tenacula,  after 
which  it  is  fastened  in  position  by  means  of  tapes  carried  around  the 
neck  and  tied  behind  (Fig.  788).     If  the  opening  be  too  small,  it  may 


Fig.  788. — Tube  in  position. 


MISCELLANEOUS   OPERATIONS. 


499 


be  increased  by  division  of  the  cricoid  cartilage  (crico-laryngotomy). 
The  size  of  the  tube  is  a  matter  of  great  importance,  since  if  it  be  too 
large  it  will  be  difficult  to  introduce  and  be  followed  by  ulceration. 
For  patients  four  years  and  under,  a  tube  with  a  caliber  of  a  fourth  of 
an  inch  is  sufficient,  in  those  four  to  eight  years  of  age,  one  third  of 
an  inch,  and  about  one  half  an  inch  for  an  adult.  The  soft  parts 
above  and  below  the  tube  are  closed  by  antiseptic  sutures,  the  patient 
is  then  placed  in  bed  and  caused  to  breathe  air  saturated  with  warm 
vapor  from  which  all  floating  particles  of  dirt  should  be  excluded. 
The  tube  is  carefully  watched  to  prevent  it  from  becoming  closed,  and 
occasionally  removed  and  cleansed.  Too  great  emphasis  can  not  be 
laid  upon  the  necessity  of  instantly  relieving  the  sudden  occlusion  of 
the  tube  due  to  false  membrane.  For  this  reason,  a  momentary  in- 
attention, as  leaving  the  room,  etc.,  may  prove  fatal  to  the  patient. 
After  three  or  four  days  the  tube  may  be  removed  and  the  patient 
allowed  to  breathe  through  the  opening  for  a  few  hours,  when  the  tube 
must  be  again  inserted  ;  later  in  the  case  it  may  be  inserted  only  during 
the  night.  As  soon  as  the  patient  can  breathe  well,  the  tube  should  be 
entirely  removed,  the  opening  closed  and  cleansed,  and  the  soft  parts 
joined  by  a  suture.  If  antiseptic  gauze  (not  bichloride)  or  adhesive 
plaster  be  placed  between  the  surface  of  the  neck  and  the  flanges  of  the 
tube,  the  danger  of  irritation  of  the  soft  parts  by  these  portions  of  the 
tube  will  be  obviated  (Fig.  788). 

Tracheotomy  is  the  operation  usually  performed  upon  children, 
owing  to  the  small  size  of  the  crico-thyroid 
space.  It  is  the  preferable  operation  in  all 
instances  when  the  incision  should  be  made 
as  far  as  possible  from  a  contagious  local 
disease.  It  may  be  done  in  three  situations 
— above,  beloiv,  and  behind  the  isthmus  of 
the  thyroid  gland  ;  the  one  below  the  isth- 
mus is  to  be  preferred.  The  upper  portion 
of  the  trachea  is  quite  superficial,  while  the 
lower  is  from  half  an  inch  to  an  inch  in 
depth,  depending  upon  the  shortness  of 
the  neck  and  the  obesity  of  the  patient. 
The  lower  portion  recedes,  following  the 
curve  of  the  spinal  column.  The  vascu- 
lar structures  in  this  portion  are  far  more 
important  and  numerous  than  in  other  parts 
of   its   course  ;    the   inferior  thyroid  veins 

I.  and  their  communications,  pass  in  the  course  of  the  incis- 
ion :  the  arteria  thyroidea  una  when  present  runs  along  the  center  of 
the  trachea  :  the  arteria  innominata,  especially  in  the  child,  runs  ob- 
liquely across  it,  at  (he  root  of  the  neck  from  left  to  right.     The  isth- 


I'ig.  789, 


— V;i«cular  relations 
of  throat. 


500  OPERATIVE   SURGERY. 

mus  of  the  thyroid  covers  the  second,  third,  and  often  the  fourth  rings 
of  the  trachea  ;  above  it  is  seen  the  communicating  branch  between  the 
superior  thyroid  veins  (Fig.  774,  d) ;  the  thymus  gland,  which  attains 
its  full  size  at  two  years,  encroaches  upon  the  space  from  below  up* 
ward  with  each  labored  respiratory  act,  and  may  be  incised.  It  is 
sometimes  difficult  for  the  beginner,  when  surrounded  by  the  turmoil 
incident  to  the  operation,  to  be  certain  of  the  locatiou  of  the  trachea. 
If  the  index-finger  be  inserted  into  the  wound,  the  trachea  will  roll  un- 
der it,  and  be  felt  ascending  and  descending  beneath  its  extremity,  and, 
when  sufficiently  isolated,  the  rings  can  be  seen  and  felt.  The  inex- 
perienced operator  is  also  likely  to  make  the  opening  at  one  side  of  the 
median  cut,  which  makes  it  difficult  to  introduce  the  tube,  causes  it 
to  bind  after  introduction,  and  not  infrequently,  if  the  tissues  overlap 
the  cut  before  its  introduction,  causes  air  to  be  forced  between  their 
planes,  creating  local  emphysema.  If  the  knife  be  inserted  too  far, 
the  posterior  wall  of  the  trachea  will  be  divided. 

Operation  beloiv  the  Isthmus. — Place  the  patient  as  for  laryn- 
gotomy,  and,  if  practicable,  administer  an  anaesthetic.  Finally,  sup- 
port the  trachea  in  the  median  line  of  the  neck  and  make  an  incision 
in  the  median  line,  extending  from  the  cricoid  cartilage  to  within 
half  an  inch  of  the  top  of  the  sternum  ;  divide  the  fascia  on  a  director  ; 
cautiously  separate  and  pull  aside  the  stern o-thyroid  and  sterno-hyoid 
muscles,  thus  exposing  the  deeper  cervical  fascia,  beneath  which  are 
located  the  inferior  thyroid  veins  (Fig.  789, 13)  supported  by  connective 
tissue.  This  fascia  should  be  torn  asunder  by  a  blunt  instrument,  and 
pushed  aside  along  with  the  veins  and  connective  tissue  beneath,  which 
will  expose  the  trachea.  The  blunt  ends  of  two  ordinary  directors  can 
be  utilized  for  separating  the  fascia,  or  instruments  especially  devised 
for  dry  dissections  can  be  employed.  Throughout  the  entire  opera- 
tion the  tissues  must  be  drawn  asunder  as  fast  as  separated,  by  means 
of  blunt  hooks  or  other  form  of  retractors,  to  afford  ample  exposure 
of  each  succeeding  part.  As  soon  as  the  trachea  is  reached  and  all 
hemorrhage  checked,  it  is  seized  by  a  hook — the  double  one  of  Lan- 
genbeck  being  the  best — drawn  forward  to  near  the  surface  of  the 
wound,  firmly  held,  and  three  or  four  rings  of  the  trachea  divided  ex- 
actly in  the  median  line  from  below  upivarcl,  by  a  sharp-pointed  knife 
(Fig.  787).  Then  the  dilator  is  introduced,  and  the  tube  inserted 
and  confined  in  position  after  the  tracheal  mucus  and  blood  have 
been  expelled.  All  incisions,  except  the  primary  one,  must  be  di- 
rected upward  to  avoid  the  great  vessels  at  the  root  of  the  neck.  The 
opening  in  the  trachea  should  be  long  enough  to  admit  the  easy  ex- 
pulsion of  all  false  membranes  and  foreign  bodies  (even  an  inch  in 
length  is  not  too  much  for  this  purpose),  and  must  likewise  readily 
admit  the  trachea  tube. 

Operation  above  the  Isthmus. — Make    an    incision  of  the   usual 


MISCELLANEOUS   OPERATIONS.  501 

length,  its  center  corresponding  to  the  lower  border  of  the  cricoid  car- 
tilage ;  divide  and  carefully  separate  the  tissues  as  before  ;  the  loop  of 
communication  between  the  superior  thyroid  veins  must  be  carefully 
drawn  upward  ;  the  fascial  attachment  between  the  isthmus  and  the 
cricoid  cartilage  divided,  the  isthmus  pulled  downward  and  drawn  for- 
ward by  a  blunt  hook,  when  the  trachea  can  be  opened  beneath  it 
from  below  upward,  and  the  tube  inserted  with  the  same  precautions 
as  before. 

Operation  through  the  Isthmus. — This  is  hardly  of  enough  prac- 
tical importance  to  be  entitled  to  a  detailed  consideration,  since  the 
opportunities  afforded  above  and  below  it  will  be  sufficient.  If,  how- 
ever, this  position  be  selected,  the  isthmus  should  be  divided  between 
two  ligatures  to  avoid  the  probability  of  troublesome  hemorrhage.  It 
sometimes  happens  that  the  isthmus  is  small  or  too  illy  developed  to 
be  troublesome  after  its  division. 

Laryngo-tracheotomy. — In  this  operation  the  larynx  and  trachea 
are  both  opened  by  a  continuous  incision,  which  is  usually  made  to 
increase  the  space,  that  foreign  bodies  and  false  membrane  may  be  re- 
moved. The  incision  through  the  cricoid  cartilage  and  upper  rings 
of  the  trachea  is  then  secondary  to  the  opening  of  the  larynx.  Before 
the  primary  incision  is  extended,  the  communicating  branches  of  the 
superior  thyroid  veins  should  be  pulled  downward,  the  lower  border 
of  the  cricoid  exposed,  its  fascial  connection  to  the  isthmus  severed, 
and  the  isthmus  drawn  downward  and  forward  as  before. 

Rapid  Laryngo-tracheotomy  (Saint-Germain). — It  is  sometimes 
necessary  to  open  the  larynx  very  quickly  ;  therefore  it  is  quite 
proper  to  mention  some  of  the  points  connected  therewith,  that  the 
surgeon  may  be  prepared  to  act  with  dispatch  combined  with  great 
caution. 

Operation. — With  the  patient  placed  in  the  usual  position  for  tra- 
cheal operations,  the  surgeon  locates  the  thyroid  and  cricoid  cartilages 
and  the  space  between  them.  Then,  standing  on  the  right  side  of  the 
patient,  he  seizes  and  pushes  forward  the  larynx  by  pressing  the 
thumb  and  index-finger  between  it  and  the  vertebral  column,  thereby 
making  the  integument  tense.  At  the  same  time  the  index-finger 
locates  the  lower  border  of  the  thyroid  cartilage.  A  straight,  sharp- 
pointed  bistoury  is  then  seized  between  the  thumb,  index,  and  middle 
fingers,  its  back  upward,  with  the  middle  finger  so  placed  that  the 
knife  can  not  penetrate  to  exceed  half  an  inch  in  depth.  While  thus 
held,  its  point  is  quickly  entered  at  the  nail  of  the  index-finger  and 
the  blade  i-  carried  downward  with  a  sawing  motion,  dividing  the 
crico-thyroid  membrane,  cricoid  cartilage,  and  one  or  two  rings  of  the 
trachea.  The  opening  through  the  integument  should  equal  in  length 
the  one  made  in  the  larynx  and  trachea.  The  dilator  is  introduced, 
all  bleeding  checked,  and  the  tracheal  tube  placed  in  position.     Saint- 


502  OPERATIVE   SURGERY. 

Germain  up,  to  1877  had  operated  by  this  method  ninety-seven  times, 
with  but  three  cases  of  hemorrhage,  and  one  in  which  the  posterior 
wall  of  the  trachea  was  cut. 

If  the  tube  be  too  large,  too  loose,  or  too  angular,  it  is  liable  to 
cause  erosions  and  ulcerations  of  the  trachea,  which  may  extend 
through  it  and  implicate  the  vessels  at  the  root  of  the  neck,  causing 
fatal  hemorrhage.  The  method  of  opening  into  the  trachea  by  a  sin- 
gle incision  is  fraught  with  danger,  and  should  not  be  attempted  ex- 
cept the  neck  of  the  patient  be  long  and  thin,  and  not  even  then  unless 
the  exigencies  of  the  case  call  for  it.  The  division  of  the  tissues  down 
to  the  trachea  by  means  of  thermo-  or  galvano-cautery  has  many  advo- 
cates ;  it  is  not,  however,  the  adopted  practice  of  this  country.  The 
searing  of  the  tissues  is  said  to  prevent  or  lessen  hemorrhage,  and 
likewise  to  obviate  the  inoculation  of  the  incision  by  contagious  germs. 
This  is  not  altogether  true,  since  the  large  veins  which  might  be  oth- 
erwise avoided  are  burned  asunder  and  too  often  cause  severe  hemor- 
rhage, which  is  not  easily  controlled  because  of  the  difficulty  of  prop- 
erly securing  the  charred  extremities  of  the  vessels.  The  resulting 
cicatrix  is  more  disfiguring  than  that  following  other  methods.  It  is 
advised  in  bronchotomy  for  diphtheria  and  acute  affections  of  the  air- 
passages  that  the  tube  be  dispensed  with,  since  it  can  only  prove  a 
source  of  local  irritation,  and  obstructs  the  exit  of  false  membranes 
and  the  secretions.  As  a  substitute,  the  borders  of  the  tracheal  open- 
ing can  be  kept  drawn  asunder  by  passing  looped  ligatures  through 
them  (Martin),  which  are  united  to  each  other  behind  the  neck.  The 
patient  must  be  carefully  watched  with  this  appliance,  since  if  the 
head  be  turned  the  opening  may  become  closed.  If  this  prove  trouble- 
some, an  elliptical  piece  can  be  removed  from  the  anterior  surface  of 
the  tube.  If  the  piece  removed  exceed  a  third  of  the  diameter  of  the 
tube,  fatal  stenosis  may  follow  its  closure. 

Results. — But  few  perish  from  the  direct  results  of  the  preced- 
ing operations.  Bronchitis,  pneumonia,  hemorrhage  from  ulceration 
through  the  trachea  caused  by  the  tube,  and  primary  hemorrhage 
from  wounds  of  the  vessels  at  the  root  of  the  neck,  or  from  any  ab- 
normally large  crico-thyroid  artery,  constitute  the  leading  causes  of 
death  directly  due  to  the  operation.  A  deeply  cyanosed  patient,  in 
the  tonic  stage  of  anaesthesia,  may  die,  especially  if  blood  be  allowed 
to  enter  the  tracheal  opening.  In  this  contingency  the  blood  must  be 
removed  at  once,  and  artificial  respiration  be  resorted  to.  Tracheoto- 
my in  diphtheria  is  undoubtedly  a  most  feasible  operation,  and  should 
be  performed  early,  before  cyanosis  is  well  established.  Dr.  Monti, 
of  Vienna,  in  his  recent  work  on  "Croup  and  Diphtheria,"  records 
12,736  tracheotomies  for  diphtheria  alone,  with  3,409  recoveries,  or 
nearly  twenty-eight  per  cent.  It  is  estimated  that  twenty-five  per 
cent  of  these  cases  have  been  saved  which  otherwise  would  have  died. 


MISCELLANEOUS   OPERATIONS. 


503 


About  twenty -seven  and  a  half  per  cent  perish  after  bronchotomy  for 
the  removal  of  foreign  bodies. 

Intubation  of  the  Larynx. — It  appears  to  be  proper  in  this  place  to 
consider  a  plan  of  treatment  of  laryngeal  obstruction  which  has  of 
late  attracted  more  than  usual  attention,  especially  in  connection  with 
the  apparatus  devised  for  the  purpose  by  Dr.  O'Dwyer,  of  this  city 
(Fig.  190).     "The  numbers  on  the  scale  (Fig.  790,  d)  indicate  the 


Fig.  790. — O'Dwyer's  instruments  for  intubation  of  the  larynx,     a.  Mouth-gag. 
b.  Introducer,  with  larynx  tubes,     c.  Extractor,     d.  Scale. 

years  for  which  the  corresponding  tubes  are  suitable.  For  instance, 
the  Bmallesi  tube  when  applied  to  the  scale  will  reach  to  the  first  line, 
marked  1,  and  is  intended  to  be  used  up  to  the  age  of  twelve  or  fifteen 
months  ;  the  size  marked  2  is  suitable  for  the  next  year,  3  and  4  for 
these  year-,  and  so  on.     When  the  proper  tube  is  selected  for  the  case 


504  OPERATIVE   SURGERY. 

to  be  operated  on,  a  fine  thread  is  passed  through,  the  small  hole  near 
its  anterior  angle,  and  left  long  enough  to  hang  out  of  the  mouth 
after  the  introduction  of  the  tube,  its  object  being  to  withdraw  the 
tube  should  it  be  found  to  have  passed  into  the  oesophagus  instead  of 
the  larynx. 

ei  The  obturator  is  then  fastened  tightly  to  the  introductor,  to  pre- 
vent the  possibility  of  its  rotating  while  being  inserted  and  passed  into 
the  tube. 

"The  following  is  the  method  of  introducing  the  tube,  which  is 
done  without  the  use  of  an  anaesthetic  :  The  child  is  held  upright  in 
the  arms  of  a  nurse,  and  the  gag  (Fig.  790,  a)  inserted  in  the  left  angle 
of  the  mouth,  well  back  between  the  teeth,  and  opened  widely ;  an 
assistant  holds  the  head,  thrown  somewhat  backward,  while  the  op- 
erator inserts  the  index-finger  of  the  left  hand  into  the  mouth  to  ele- 
vate the  epiglottis  and  draw  the  bone  of  the  tongue  forward,  and  at 
the  same  time  direct  the  tube  into  the  larynx. 

"  The  handle  of  the  introductor  (Fig.  790,  b)  is  held  close  to  the 
patient's  chest  in  the  beginning  of  the  operation,  and  rapidly  elevated 
as  the  canula  apprcaches  the  glottis.  The  tube  is  then  pushed  down- 
ward, without  using  much  force.  The  tube  is  then  detached.  The 
joint  in  the  shank  of  the  obturator  is  for  the  purpose  of  facilitating 
this  part  of  the  operation.  As  soon  as  the  obturator  is  removed,  and 
it  is  ascertained  that  the  tube  is  in  the  larynx,  the  thread  is  with- 
drawn, but  at  the  same  time  the  finger  is  kept  in  contact  with  the 
tube  to  prevent  its  being  also  withdrawn. 

"  It  is  important  that  the  attempt  at  introduction  be  made  quickly, 
as  respiration  is  practically  suspended  from  the  time  that  the  finger 
enters  the  larynx  until  the  obturator  is  removed.  It  is,  therefore, 
under  the  circumstances,  much  safer  to  make  several  abortive  attempts 
than  one  prolonged  effort,  even  if  successful. 

"For  the  purpose  of  removal,  the  patient  is  held  in  a  similar  posi- 
tion, except  that  the  head  is  not  inclined  backward,  or  very  slightly 
so,  and  the  extractor  (Fig.  790,  c)  passed  into  the  tube  guided  by  the 
index-finger  of  the  left  hand,  which  also  fixes  the  epiglottis,  and  is 
brought  in  contact  with  the  head  of  the  canula.  Firm  pressure  with 
the  thumb  is  then  made  on  the  lever  above  the  handle  while  the  tube 
is  being  withdrawn.  If  secondary  dyspnoea  supervenes  at  any  time, 
the  tube  should  be  removed  and  a  larger  one  substituted.  These 
tubes  will  also  prove  valuable  as  dilators  in  chronic  stenosis  of  the 
larynx  or  trachea." 

It  is  recommended  by  Dr.  O'Dwyer  that  preliminary  practice  in 
the  introduction  and  removal  of  the  tube  be  had  upon  the  cadaver 
when  this  means  of  gaining  experience  is  feasible.  The  removal  of 
the  tube  is  more  difficult  than  the  introduction,  on  account  of  the 
trouble  of  inserting  the  blades  of  the  extractor  into  the  open  upper 


MISCELLANEOUS   OPERATIONS.  505 

end  of  the  tube  while  more  or  less  completely  hidden  from  view  by  the 
natural  position  of  the  surrounding  soft  parts.  This  part  of  the 
operation  becomes  especially  troublesome  when  the  patient  offers  any 
opposition  to  the  attempt,  and  it  may  become  necessary  under  these 
circumstances  to  administer  an  anesthetic  before  the  tube  can  be 
safely  removed. 

Prognosis. — The  rate  of  mortality  in  laryngeal  obstruction  when 
treated  by  this  method  is  not  as  yet  well  established,  although  it  ap- 
pears thus  far  to  compare  favorably  with  that  following  either  of  the 
varieties  of  brouchotomy.  This  plan  certainly  offers  especial  advan- 
tages for  the  treatment  of  stenosis  of  the  larynx  from  other  causes, 
and  for  the  relief  of  those  cases  of  acute  stenosis  for  which  the 
friends  of  the  patient  refuse  tracheotomy  as  a  means  of  relief. 

Foreign  Bodies  in  the  Bronchi. — It  is  advisable  to  endeavor  to  ex- 
tract a  foreign  body  located  in  either  bronchus  rather  than  to  trust  to 
nature  to  expel  it.  Its  site  should  be  carefully  determined  by  auscul- 
tation— it  is  more  frequently  located  on  the  left  side — before  the  open- 
ing is  made  in  the  trachea.  After  this,  if  a  flexible  probe  be  passed 
through  the  opening  in  the  lice  of  the  suspected  bronchus,  it  may  be 
easily  detected.  The  foreign  body  may  be  grasped  by  forceps  of  a 
proper  shape  and  size,  or  a  wire  with  a  hooked  extremity  may  be 
passed  beyond  it,  and  withdrawn,  thus  displacing  or  removing  the 
obstruction.  A  loop  of  surgical  silver  wire,  as  suggested  by  Dr.  J. 
L.  Little,  can  be  pushed  past  it,  turned  somewhat  and  withdrawn 
with  the  best  of  results.  In  any  instance  no  harm  can  be  done  by 
this  simple  agent.  Half  an  hour  is  quite  sufficient  time  to  continue 
the  manipulation. 

Thyrotomy. — This  operation  consists  in  dividing  the  thyroid  car- 
tilage exactly  in  the  median  line,  together  with  the  crico-thyroid-and 
thyro-hyoid  membranes  when  additional  room  is  desired.  Morbid 
growths  and  foreign  bodies  in  the  larynx,  below  the  false  vocal  cords, 
which  threaten  death  from  asphyxia  and  can  not  be  removed  through 
the  mouth,  demand  its  performance.  It  is  wise  to  anticipate  the  dan- 
ger that  may  arise  from  the  passage  of  blood  into  the  trachea,  by  pre- 
liminary tracheotomy,  especially  if  the  tumor  be  a  large  or  a  very  vas- 
cular one. 

Operation. — Place  the  patient  as  for  tracheotomy  ;  administer 
an  anaesthetic  ;  make  an  incision  an  inch  and  a  half  in  length  in  the 
median  line,  extending  from  the  hyoid  bone  downward  ;  divide  the 
fascia  on  a  director;  separate  the  sterno-hyoid  muscles,  and  with  a 
grooved  director  press  aside  the  tissues  beneath,  and  expose  the  angle 
of  the  thyroid  cartilage.  If  the  patient  be  a  child,  this  will  be  some- 
what difficult  to  discern,  even  after  the  exposure  ;  still,  the  center  of 
the  notch  at  the  upper  and  lower  borders  of  Ihc  cartilage  marks  the 
extremities  of  the  line  of  the  incision  to  be  mado.     The  cartilage  is 


506  OPERATIVE   SURGERY. 

held  firmly  by  a  tanaculum,  and  the  division  made  exactly  in  the  me- 
dian line,  with  a  sharp-pointed  knife,  down  to  the  mucous  lining 
within.  If  it  be  divided  at  either  side  of  the  median  line,  the  origin 
of  the  corresponding  vocal  cord  will  be  cut.  After  all  hemorrhage  is 
checked,  the  mucous  lining  is  divided  and  the  lips  of  the  cartilage 
wound  separated  by  hooked  retractors,  and,  if  need  be,  the  incision 
extended  through  the  membranes  above  and  below.  The  obstruction 
is  then  removed  and  the  cartilage  accurately  apposed  and  united  by 
fine  catgut.  The  soft  parts  are  then  united  and  treated  antiseptically. 
If  the  cartilage  be  not  accurately  joined,  the  functions  of  the  vocal 
cords  will  be  impaired,  owing  to  their  abnormal  relations  to  each 
other.  If  the  cartilaginous  ridge  be  nicked  transversely  before  its 
division,  it  can  be  accurately  apposed  thereafter  by  joining  the  carti- 
laginous borders  on  the  line  of  the  nicks. 

Results. — Nearly  eight  and  one  half  per  cent  die  from  the  opera- 
tion. 

Sub-hyoid  Laryngotomy,  or  Pharyngotomy. — This  operation  is  ad- 
missible for  the  removal  of  foreign  bodies  and  morbid  growths  situ- 
ated high  up  in  the  air-passage,  and  for  the  relief  of  abscesses  at  the 
base  of  the  epiglottis. 

Operation. — Place  the  patient  as  for  laryngotomy  ;  administer  an 
anaesthetic,  and  make  an  incision  an  inch  and  a  half  or  two  inches  in 
length  transversely  along  the  lower  border  of  the  hyoid  bone,  with  its 
center  in  the  median  line.  The  integument,  fascia,  platysma,  and  the 
inner  portions  of  each  sterno-hyoid  muscle,  and  finally  the  thyro- 
hyoid, are  divided  on  a  director.  The  only  vessel  contiguous  to  the 
incision  is  the  superior  thyroid  artery,  which  runs  along  the  upper  bor- 
der of  the  thyroid  cartilage,  parallel  with  the  incision.  As  soon  as 
the  thyro-hyoid  membrane  is  cut,  the  epiglottis  will  project  through 
the  opening,  and  must  be  drawn  aside,  when  the  tumor  will  be  ex- 
posed to  view.  After  the  removal  of  the  growth,  the  wound  is  closed 
and  dressed  antiseptically.  The  majority  of  the  conditions  calling  for 
this  operation  can  be  satisfactorily  treated  through  the  mouth. 

Prognosis. — The  operation  itself  implies  no  unusual  danger  to  the 
patient. 

Laryngectomy. — The  removal  of  the  entire  larynx  is  not  a  difficult 
operation  if  the  surrounding  tissues  be  not  involved  by  the  disease. 

Operation. — Make  a  vertical  incision  in  the  median  line  from  the 
hyoid  bone  to  the  second  ring  of  the  trachea ;  free  the  sides  of  the 
larynx  from  its  muscular  attachments  without  opening  into  it ;  draw 
the  trachea  forward  with  a  hook  and  separate  it  transversely  from  the 
larynx ;  a  siphon-tube  of  vulcanite  is  then  introduced,  or  the  Tren- 
delenburg tampon,  to  prevent  the  entrance  of  blood,  and  at  the  same 
time  afford  a  proper  channel  for  the  use  of  the  anaesthetic.  If  there 
be  much  oozing  of  blood,  the  head  may  be  lowered  to  cause  it  to  flow 


MISCELLANEOUS   OPERATIONS.  507 

from  the  trachea,  when  the  posterior  and  upper  connections  of  the 
larynx  are  severed.  The  oesophagus  must  be  carefully  located,  or  it 
may  be  cut.  The  tissues  should  be  separated  by  the  fingers  when  pos- 
sible, aided  by  blunt-poiuted  scissors.  The  amount  of  hemorrhage 
is  trifling  and  easily  controlled  ;  the  branches  of  the  superior  and  in- 
ferior thyroid  vessels  furnish  the  principal  bleeding  points,  and  these 
should  be  tied  and  divided  between  two  ligatures  before  the  growth  is 
separated  from  its  connections.  The  after-treatment  consists  in  keep- 
ing the  parts  thoroughly  cleansed,  and  regulating  the  temperature  of 
the  room,  together  with  careful  attention  to  the  tracheal  tube.  It 
often  happens  that  in  addition  to  the  larynx  the  hyoid  bone,  base  of  the 
tongue,  pharynx,  and  oesophagus,  are  involved  in  a  malignant  growth. 
The  first  step  under  these  circumstances  is  to  introduce  the  tampon 
eanula  of  Trendelenburg,  or  a  substitute,  through  which  the  anaes- 
thetic is  administered.  Make  a  transverse  incision  through  the  skin 
from  the  inner  edge  of  one  sterno-mastoid  muscle  to  the  other,  pass- 
ing half  an  inch  above  the  hyoid  bone  ;  from  this  carry  a  second  one 
vertically  downward  along  the  median  line  of  the  trachea  to  the  in- 
cision made  to  open  the  trachea  ;  turn  the  flaps  outward  ;  remove  all 
large  glands  in  the  vicinity ;  divide  the  muscular  attachments  to  the 
hyoid  bone  ;  tie  the  lingual  and  superior  thyroid  arteries  ;  excise  the 
tongue  below  the  disease,  along  with  the  palato-pharyngeal  arches  if 
necessary,  carefully  avoiding  the  external  carotid  arteries,  when  it  is 
possible  ;  if  not,  draw  them  forward  along  with  the  pharynx  and 
divide  them  between  two  ligatures  ;  cut  the  lingual  and  hypoglossal 
nerves.  The  larynx  is  now  separated  from  the  trachea  by  cutting 
the  latter  just  below  the  cricoid  cartilage  ;  a  eanula  is  introduced 
into  it;  the  parts  are  thoroughly  washed  with  a  carbolized  solution  ; 
the  flaps  placed  in  contact  with  the  raw  surfaces  without  sutures,  and 
the  wound  sprinkled  with  iodoform.  If  the  oesophagus  be  divided, 
its  lower  extremity  must  be  kept  open  and  so  placed  that  it  can  be 
protected  from  the  entrance  of  discharges,  and  become  an  available 
channel  through  which  to  nourish  the  patient. 

Results. — The  prognosis  of  complete  extirpation  is  better  than  the 
partial.  In  speaking  of  the  results,  Prof.  S.  D.  Gross  says  :  "  Of 
thirty-seven  complete  excisions,  nineteen  recovered  and  eighteen  died, 
at  periods  varying  from  ten  to  sixteen  days,  the  cause  of  death  in 
twelve  having  been  pneumonia.  Of  the  entire  number  thirty  were  for 
carcinoma,  of  which  sixteen  perished  from  the  effects  of  the  operation  ; 

ii  died  of  the  recurrence  of  the  disease  in  from  four  to  nine 
months  ;  one  died  from  an  accident,  and  six  were  still  living."  After 
the  extirpation  of  the  larynx,  its  place  may  be  supplied  by  an  artificial 
Appliance  which,  although  ingenious,  serves  as  a  poor  substitute  for 
the  normal  parts. 

Cohen,  of  Philadelphia,  in  a  paper  on  "Does  Excision  of  the  Lar- 


508  OPERATIVE   SURGERY. 

ynx  tend  to  the  Prolongation  of  Life?"  gives  the  results  of  sixty-five 
complete  operations,  over  forty  of  which  were  done  for  carcinoma. 
Without  entering  into  the  details  of  the  cases,  it  is  sufficient  to  add 
that  Dr.  Cohen  is  of  the  opinion  that  tracheotomy  and  simpler  means 
give  a  much  better  chance  of  prolonging  life. 

Removal  of  a  Goitre  (Watson). — When  the  patient  is  in  danger  of 
suffocation,  it  is  admissible  to  attempt  the  removal  of  the  growth, 
which  is  done  in  the  following  manner  : 

Operation. — The  patient  is  placed  in  the  dorsal  position  with  the 
head  situated  so  as  to  afford  the  best  opportunity  for  breathing  ;  care- 
fully administer  an  anaesthetic  ;  make  a  free  incision  in  the  median 
line  from  the  upper  part  of  the  growth  to  the  sternal  notch  ;  divide 
all  the  tissues  on  a  director  in  the  line  of  the  incision  down  to  the 
capsule  ;  draw  aside  the  muscles  covering  the  growth  if  its  size  will 
permit ;  if  not,  cut  them  transversely  on  a  director  ;  secure  all  bleed- 
ing points  as  fast  as  seen  ;  separate  the  cervical  fascia  from  the  capsule 
of  the  tumor  with  the  fingers,  down  to  the  thyroid  arteries,  which 
must  be  ligatured.  All  fibrous  connections  between  the  capsule  and 
the  fascia  should  be  tied  before  they  are  cut.  The  capsule  can  now 
be  opened  and  its  attachments  to  the  growth  severed  by  the  scissors. 
If  the  capsule  be  opened  before  the  arteries  are  ligatured,  the  hemor- 
rhage will  be  profuse  and  the  ability  to  control  it  limited.  After  all 
hemorrhage  has  ceased,  the  wound  is  closed  with  catgut  sutures, 
drained,  and  dressed  antiseptically. 

Results. — The  chance  for  the  life  of  the  patient  is  flattering.  Since 
the  plan  of  operation  just  described  has  been  practiced,  less  than  seven 
per  cent  have  perished  from  it.  The  operation  has  been  performed 
about  three  hundred  and  forty-five  times  since  1877.  Recently,  when 
done  with  antiseptic  precautions,  a  large  proportion  have  proved  suc- 
cessful. Total  extirpation  is  no  more  fatal  than  incomplete.  Kocher 
has  pointed  out  the  fact  that,  if  the  thyroid  body  be  removed  before 
adolescence,  cachexia  followed  by  idiocy  of  the  patient  are  common 
sequels. 

Arthrectomy. — The  performance  of  this  operation  is  limited  sub- 
stantially to  the  knee-joint,  and  consists  in  forming  a  flap  by  a  semi- 
lunar incision,  similar  in  its  outline  to  the  one  emplo}red  in  excision  of 
the  knee.  The  flap  is  reflected  upward,  and  the  capsule  opened  at 
each  side  of  the  patella  and  its  ligament,  or  the  patella  may  be  sawn 
across  and  the  fragments  turned  upward  and  downward.  The  re- 
mainder of  the  operation  consists  in  the  careful  removal  of  all  the 
diseased  portions  of  bone,  cartilage,  synovial  membrane,  and  liga- 
ment, with  scissors,  scoops,  etc. 

The  most  difficult  part  of  the  operation  is  the  removal  of  the  pos- 
terior portions  of  the  semilunar  cartilages  and  the  synovial  membrane 
at  the  posterior  part  of  the  joint.     Much  time  and  patience  are  neces- 


MISCELLANEOUS   OPERATIONS. 


509 


sarv  to  faithfully  meet  the  indications  of  this  operation.  After  all 
hemorrhage  has  ceased,  the  entire  cavity,  including  the  upper  syno- 
vial pouch,  must  be  thoroughly  cleansed  and  drained,  and  an  anti- 
septic dressing  applied  to  the  limb. 

Prognosis. — The  results  thus  far  do  not  warrant  the  belief  that  this 
operation  can  be  employed  as  a  suitable  substitute  for  excision,  except, 
perhaps,  in  those  cases  where  suppuration  is  slight,  disease  of  the 
bone  superficial  and  circumscribed,  and  when  no  constitutional  vice  is 
present. 

Wiring  the  Patella. — The  generally 
accepted  opinion  that  this  operation  is 
a  justifiable  measure  in  selected  cases, 
and  under  suitable  conditions,  requires 
that  its  modus  operandi  be  given  some 
attention. 

Operation.  —  An  incision  is  made 
transversely  across  the  joint  from  one 
condyle  to  the  other,  passing  between 
the  fragments  of  the  bone  and  freely  ex- 
posing the  joint-cavity.  All  blood-clots 
and  bony  asperities  are  removed  from 
the  broken  borders  of  the  fragments. 
The  lacerated  tissues  about  the  joint  are 
trimmed  away  and  the  blood-clots  turned 
out.  The  fibrous  tissues  at  the  broken 
borders  of  the  bone  are  trimmed  off 
closely.  Every  form  of  blood  and  for- 
eign substance  must  be  removed  from 
the  joint-cavity,  especial  care  being  tak- 
en to  cleanse  the  upper  synovial  pouch 
and  the  posterior  aspect  of  the  joint. 
Drainage  should  be  made  through  the 
posterior  wall  at  each  condyloid  depres- 
sion, carefully  avoiding  the  nerves  and 
le  in  the  popliteal  space.  The  frag- 
ments are  then  drilled  (Fig.  791),  and 
one  or  more  wire  sutures  introduced 
(Fig.  792).  The  joint-cavity  is  again 
thoroughly  cleansed,  all  hemorrhage 
checked,  and  the  fragments  placed  in 
contact  with  each  other,  the  sutures 
tightened,  their  ends  twisted  together, 
lort  and  turned  inward  from  the 
surface  (Pig.  793).  The  cut  borders  of  the  capsule  of  the  joint  are 
united    independently   by   a  continuous  suture  of  fine  catgut,  after 


Fio.  791. — French  bone-drill. 


510 


OPERATIVE   SURGERY. 


which  the  superficial  tissues  are  joined  by  catgut  of  a  larger  size. 
Horse-hair  drainage  may  be  made  at  the  sides  between  the  tissues 


Fig.  792. — Wire  introduced. 


Fig.  793. — Fragments  united. 


joined  by  the  two  rows  of  sutures.  The  antiseptic  douching  should 
be  continuous  during  the  entire  operation.  The  external  dressings 
are  applied,  and  the  limb  is  immovably  fixed  in  an  extended  position. 
After  a  week  or  ten  days  fresh  dressings  are  applied,  and  the  drainage 
agents  removed  ;  if  suppuration  has  not  occurred,  one  redressing  may 
suffice.  Yet  it  is  better  to  again  redress  the  limb  after  a  week  or  so, 
when,  if  the  wounds  be  healed,  the  limb  can  be  confined  in  a  plaster- 
of- Paris  splint  and  the  patient  permitted  to  move  around.  The  op- 
eration may  be  performed  at  any  time  during  the  first  week  or  ten 
days  after  the  injury.  If  the  fracture  be  compound,  it  should  be 
wired  at  once.  In  an  old  case,  when  the  quadriceps  extensor  tissues 
have  become  contracted  and  atrophied,  a  V-shaped  incision  through  its 
structure  may  be  necessary  in  order  to  bring  the  freshened  edges  of 
the  fragments  in  contact.  The  olecranon  process,  when  fractured, 
may  likewise  be  wired.  The  wire  sutures  need  not  be  removed  at  all 
unless  they  cause  trouble.  Silk-worm  gut  is  sometimes  employed  for 
this  purpose,  instead  of  the  silver  wire. 

Results. — Prior  to  1883  the  patella  had  been  wired  forty-nine 
times,  of  which  two  of  the  patients  died,  one  of  pyaemia  and  one  of 
exhaustion.  Besides  these,  six  cases  resulted  in  suppuration  and  an- 
chylosis. During  the  last  two  years  upward  of  a  hundred  and  forty 
cases  have  been  reported,  in  a  few  of  which  suppuration  has  occurred, 
and  in  two  or  three  death  has  followed.  In  my  opinion,  this  measure 
should  not  be  employed  except  for  other  reasons  than  that  of  the 
existence  of  a  simple  fracture  of  the  bone,  because  I  do  not  believe 
that  it  is  good  surgery  to  expose  a  patient  to  the  contingencies  of 
suppuration,  amputation,  anchylosis,  and  even  death,  for  the  better 
rectification  of  an  injury,  which  at  its  worst  has  no  tendency  to  ter- 
minate fatally,  and  almost  invariably  results  in  a  serviceable  limb 
when  treated  by  the  ordinary  methods. 

Movable  Bodies  in  Joints. — Movable  bodies  in  joints  not  infre- 
quently become  a  source  of  so  much  annoyance  that  the  comfort  of 


MISCELLANEOUS  OPERATIONS.  511 

the  patient,  as  well  as  the  usefulness  of  the  limb,  demand  their  re- 
moval. Ordinarily  these  bodies  appear  at  intervals  at  some  point  cor- 
responding to  the  external  line  of  the  articulation,  where  they  can  be 
easily  felt,  and  where  they  will  remain  until  displaced  into  the  articu- 
lation again  by  movements  of  the  joint  or  by  manual  manipulation. 

Operation. — An  attempt  to  remove  these  bodies  should  not  be 
made  except  under  strict  antiseptic  precautious.  The  patient  is. given 
an  anaesthetic,  or,  if  the  object  be  a  small  one,  an  injection  of  cocaine 
may  be  employed  instead.  After  the  movable  body  is  fixed  firmly  in 
position  by  passing  into  it  through  the  superficial  tissues  a  sharp- 
pointed  awl-like  instrument,  an  incision  is  made  directly  down  upon 
it,  all  bleeding  checked,  and  the  synovial  lining  of  the  joint  is  carefully 
opened  sufficiently  to  permit  the  introduction  of  a  strong  pair  of 
sharp-toothed  forceps,  by  which  the  movable  body  is  grasped  and  care- 
fully drawn  through  the  incision  in  the  soft  parts.  If  it  be  adherent 
to  the  deeper  joint-structure,  it  may  be  either  pulled  or  cut  away. 
The  wound  is  closed  by  two  rows  of  sutures,  one  of  fine  catgut,  that 
unites  the  borders  of  the  synovial  membrane  and  its  subjacent  tissue, 
the  second  completely  unites  the  remaining  tissues.  A  few  strands  of 
horse-hair  or  catgut  introduced  between  the  tissues  united  by  the  two 
rows  of  sutures  are  sufficient  for  suitable  drainage.  The  limb  is  now 
dressed  antiseptically  and  immovably  fixed  in  the  extended  position. 
At  the  end  of  four  or  five  days  the  dressing  is  removed,  drainage 
agents  withdrawn,  and  the  limb  redressed  as  in  the  first  instance.  If 
the  drainage  agents  are  composed  of  a  material  that  can  be  absorbed, 
one  dressing  may  suffice  for  the  entire  treatment  of  the  case.  If  the 
foreign  bodies  be  not  accessible  during  their  wanderings,  it  may 
become  necessary  to  open  the  joint  in  front  by  a  free  incision  to  re- 
lieve the  suffering  of  the  patient.  Flexion  and  extension  of  a  joint 
often  aid  in  the  removal  of  these  bodies. 

Prognosis. — The  danger  to  life  or  limb  is  trivial  when  the  opera- 
tion is  performed  antiseptically.  Relief  from  the  suffering  is  certain 
if  all  the  offending  agents  be  removed. 

Ganglion  is  a  name  applied  to  a  limited  though  abnormal  collec- 
tion of  fluid  found  in  connection  with  the  sheaths  of  tendons,  and 
situated  most  commonly  at  the  back  of  the  wrist,  although  found  not 
infrequently  at  the  anterior  surface  and  in  the  palm.  It  is  also  de- 
pendent on  the  protrusion  of  the  synovial  lining  of  the  carpal  articular 
surfaces  through  a  rupture  of  the  fibrous  sheath  by  which  they  are 
connected  with  each  other. 

Two  methods  of  treatment  are  commonly  employed  :  1.  The  simple 
or  palliative  method.     2.   The  radical  or  curative  method. 

The  palliative  method  comprises  simple  measures,  such  as  rest  to 
the  part,  pressure,  counter-irritation,  tapping,  etc.  These  measures 
arc  sometimes  followed  by  permanent  recovery. 


512  OPERATIVE   SURGERY. 

The  radical  method  has  two  distinct  plans  of  procedure  :  1.  The 
rupture  of  the  ganglion  by  pressure  with  the  thumbs  or  by  a  sharp, 
quick  blow  with  the  back  of  a  book,  while  the  hand  is  placed  on  the 
knee.  After  this  the  simple  measures  may  be  employed.  2.  The  sac 
may  be  divided  subcutaneously,  under  antiseptic  precautions,  or  a  free 
incision  may  be  made  through  the  soft  parts  down  to  the  sac.  It  is  then 
opened,  the  contents  evacuated,  and  the  borders  trimmed  sufficiently 
to  permit  their  union,  which  is  accomplished  by  sewing  them  with  a 
continuous  suture  of  fine  catgut.  Antiseptic  precautions  should  be 
rigidly  enforced  during  and  subsequent  to  this  plan  of  operation.  It 
sometimes  becomes  necessary  to  scooj)  or  dissect  out  the  diseased 
membrane,  especially  when  the  disease  is  in  the  course  of  the  tendi- 
nous sheaths  of  the  digits,  before  a  cure  can  be  effected. 

The  injection  of  irritating  fluids,  such  as  tincture  of  iodine,  etc., 
is  recommended  with  much  reserve. 

Prognosis. — The  radical  method  of  treatment  is  the  only  one  that 
offers  a  fair  prospect  of  cure,  and  this  is  not  usually  successful  unless 
the  diseased  membrane  be  treated  by  means  of  direct  incision.  If  it 
become  necessary  to  dissect  or  scrape  away  the  synovial  sheaths,  the 
prognosis  of  usefulness  of  these  digits  is  somewhat  dubious.  How- 
ever, so  far  as  the  preservation  of  life  and  limb  is  concerned,  neither 
is  exposed  to  unusual  danger  if  the  surgical  principles  of  antisepsis  be 
strictly  observed. 

Wiring  of  Bones  for  Compound  Fractures. — This  operation  is  con- 
sidered now  to  be  an  entirely  proper  one,  when  it  can  be  done  with 
strict  antiseptic  precautions.  It  is  indicated  especially  if  the  tendency 
to  displacement  of  the  fragments  be  great,  due  to  either  involuntaryor 
voluntary  muscular  movements. 

Operation. — Administer  an  anaesthetic,  and  employ  all  antiseptic 
precautions.  Enlarge  the  wound  of  the  soft  parts  in  the  direction  best 
intended  to  expose  to  view  the  injuries  of  the  deeper  tissues  and  to 
avoid  injury  of  the  blood-vessels  and  nerves.  Trim  off  the  bruised 
portions  of  the  soft  parts,  both  deep  and  superficial,  with  scissors. 
The  periosteum  should  be  carefully  preserved,  and  be  replaced  in  the 
normal  position,  when  possible,  even  if  it  have  been  detached  from  the 
bone.  The  disconnected  fragments  of  bone,  and  other  loose  portions 
of  bone  that  can  not  be  preserved,  should  be  taken  away.  Eemove  the 
blood-clots,  check  the  haemorrhage,  and  make  counter-openings  for 
drainage.  The  fracture  is  now  reduced,  and  the  remaining  fragments 
are  drilled  and  united  together  firmly  with  fine  silver  wire  or  silk- worm 
gut.  The  drainage-tubes  are  then  introduced,  the  openings  of  the 
soft  parts  are  closed  by  catgut  sutures,  the  limb  dressed  antiseptically, 
and  immovably  fixed  by  being  incased  in  a  plaster-of- Paris  splint,  or 
with  strips  of  tin  or  iron  placed  longitudinally.  The  general  princi- 
ples relating  to  antiseptic  dressings  should  be  observed  in  the  further 


MISCELLANEOUS   OPERATIONS.  513 

treatment  of  the  case.     The  wire  sutures  need  not  be  removed  unless 
they  cause  trouble. 

Prognosis. — The  prognosis  is  excellent.  Many  useful  limbs  have 
been  gained  by  this  method,  combined  with  strict  antisepsis,  perfect 
immobility,  and  suspension,  that  would  otherwise  have  been  amputated 
or  have  recovered  with  great  loss  of  function. 

33 


IISTDEX. 


Abdominal  aorta,  ligature  of.  60. 

linear  guide  to,  60. 
Abdominal  section,  362. 

explorative,  362. 
Abdominal  tourniquet,  Brandis',  287. 

Esmarch's,  287. 

Lister's,  2S7. 

Lloyd's,  289. 

Paricoast's,  287. 
Abscess  in  the  right  iliac  fossa,  373. 

perityphlitic,  37o. 
Actual  cautery,  35. 
Acupressure,  31. 

pins,  32. 
Adams'  operation  for  subcutaneous  division 

of  the  neck  of  the  femur,  216. 
Adductor  magnus,  tenotomy  of,  158. 
Agents  for  controlling  hemorrhage,  23. 
Agnew's  operation  for  radical  cure  of  in- 
guinal hernia,  383. 
Air  in  the  veins,  55. 

symptoms,  55. 

treatment  of,  55. 

preventive  treatment  of,  55. 
Allis'  ether-inhaler,  8. 
Amputating  knife,  manner  of  grasping  the, 
230. 

knives,  230. 

knives,  the  catlin,  231. 

saw,  proper  method  of  using  an,  233. 
•    232. 
Amputation,  agents  required  for,  230. 

circular  method,  224. 

circular  method,  modified,  226. 
ification  of  flaps,  224. 

comparative  merits  of  different  forms  of 
flaps,  230. 

doable-flap  method,  227. 

equilateral  Baps,  229. 

bood  flap,  229. 

how  to  operate,  286. 

Langenbeck'e  method,  228. 

mixed  double-flap  method,  228. 

oval  method,  227. 

periosteal  flap,  229. 

rectangular-flap  method,  228. 

single-flap  method,  227. 

Teale'i  method,  22s. 

tli'-  retractor  in,  286. 


Amputation  at  the  ankle-joint,  Pirogoff,  270. 

Bruns'  modification  of  Pirogoff's,  272. 

Esmarch's  modification  of  Le  Fort's,  273. 

Fergusson's    modification   of   Pirogoff's, 
271. 

Le  Fort's  modification  of  Pirogoff's,  272. 

Roux's,  269. 

Syme's,  267. 

modification  of  Syme's,  26S. 
Amputation  of  the  arm,  248. 

circular-flap  method,  248. 

large  anterior  and  small  posterior  flaps, 
250. 

musculocutaneous  flaps,  Langenbcck,  249. 

unequal  double-flap  method,  249. 
Amputation  at  the  elbow-joint,  247. 

circular  method,  247. 

single-flap  method,  248. 
Amputation  of  the  forearm,  246. 

circular  method,  246. 

equilateral  skin-flaps,  246. 

musculocutaneous  flaps,  247. 
Amputation  at  the  hip-joint,  287. 

anterior  oval  method,  Vcrneuil,  296. 

circular  method,  Dieffenbach,  292. 

lateral-flap  method,  296. 

long   anterior   and   short  posterior   flap, 
Maenec,  290. 

single-flap  method,  Malgaigne,  293. 
Amputation  at  the  knee-joint,  278. 

bilateral  method,  279. 

circular  method,  280. 

long  anterior,  with  a  short  posterior  flap, 
281. 

through  the  condyles,  281. 

through  the  condyles,  Garden,  282. 

through  the  condyles,  Gritti,  283. 

Stokes'  modification  of  Giitti's,  283. 
Amputation  of  the  leg,  lower  third,  274. 

lower  third,  bilateral  method,  276. 

lower  third,  circular,  with  periosteal  re- 
flection,  274. 

lower  third,  hood  or  oval  flap,  277. 

middle  third,  277. 

middle  third,  unilateral-flap  method,  278. 

supra-malleolar,  274. 
upper  third,  2Y8. 
Amputation,  lower  extremity,  255. 

through   m<-dio  tarsal  joint,  Chopart,  262. 


516 


INDEX. 


Amputation     through     medio-tarsal    joint, 
Forbes'  modification  of  Chopart's,  264. 
of  the  last  four  metacarpal  bones,  243. 
through  the  metacarpal  bones,  242. 
Amputation  at  the  metacarpo-phalangeal  ar- 
ticulation, 239. 
through  all  the  metatarsal  bones,  258. 
Amputation,  osteoplastic,  of  heel  and  ankle, 

Mikulicz,  273. 
Amputation  of  the  penis,  old  plan,  462. 
Hilton's  modification,  462. 
Humphrey's  modification,  463. 
Amputation  at  phalangeal  articulations  of 

the  hand,  23*7. 
Amputation  above  the  shoulder-joint,  255. 
Amputation  at  the  shoulder-joint,  250. 
by  circular  incision,  252. 
by  internal  and  external  flaps,  Dupuytren, 

250. 
by  oval  method,  Larrey,  252. 
Spence's  method,  253. 
Amputation,  subastragaloid,  De  Lignerolles, 
264. 
subastragaloid,  Hancock,  266. 
subastragaloid,  Tripier's  method,  266. 
Amputation,  tarsal,  irregular,  Moliere,  266. 
Amputation   at  the  tarso-metatarsal  joint, 
Lisfranc,  260. 
Bauden's  modification  of  Lisfranc's,  262. 
Hey's  modification  of  Lisfranc's,  262. 
Skey's  modification  of  Lisfranc's,  262. 
Amputation  of  the  thigh,  283. 

antero-posterior   musculo  -  integumentary 

flaps,  285. 
bilateral  method,  284. 
circular  integumentary  flap,  285. 
long  anterior-flap  method,  Sedillot,  286. 
single  circular   incision  method,  Celsus, 
285. 
Amputation  of  the  thumb,  at  the  carpo-mcta- 
carpal  articulation,  lateral-flap  method, 
241. 
at  the  carpo-metacarpal  articulation,  oval 
method,  240. 
Amputation  of  the  toe,  fifth,  with  its  meta- 
tarsal bone,  lateral-flap  method,  259. 
fifth,  with  its  metatarsal  bone,  259. 
great,  by  large  square  internal  flap,  257. 
great,  with  its  metatarsal  bone,  259. 
Amputation  of  the  toes,  all,  at  the  metatarso- 
phalangeal joint,  258. 
of  toes,  in  their  continuity,  255. 
of  toes,  two  adjoining,  257. 
of  single  toes,  256. 
of  single  toes,  by  lateral  flap,  256. 
Amputation  of  upper  extremities,  236. 
Amputation  at  the  wrist-joint,  244. 
circular  method,  244. 
double-flap  method,  Ruysch,  244. 
radial  flap,  Dubrueil,  245. 
single  palmar-flap  method,  245. 
Amputations,  223. 
Amussat's  operation  of  left  lumbar  coloto- 

my,  368. 
Anaesthesia,  how  to  prepare  a  patient  for,  12. 


Anaesthesia,  local,  16. 
Anaesthetic,  purity  of,  11. 
Anaesthetics,  5. 

inhalers  for,  7. 
Anchylosis,  297. 

bony,  of  knee-joint,  supra-condyloid,  oste- 
otomy for,  217. 

of  inferior  maxilla,  178. 

of  inferior  maxilla,  removal  of  a  wedge- 
shaped  piece,  Esmarch,  179. 
Aneurism-needle,  59. 

Fletcher's,  60. 

Mott's,  59. 

students',  60. 

Syme's,  59. 
Anger's  opei'ation  for  hypospadias,  464. 
Ankle  and  heel,  osteoplastic  amputation  at, 

Mikulicz,  273. 
Ankle-joint,  amputation  at,  Bruns,  272. 

Fergusson's   modification    of    Pirogoff's, 
271. 

Le  Fort's  modification  of  Pirogoff's,  272. 

Le  Fort's  modification  of  Esmarch's,  273. 

Pirogoff's,  270. 

Roux's,  269. 

Syme's,  267. 

Syme's,  modification  cf,  268. 
Ankle-joint,  excision  of,  199. 

excision   of,    subperiosteal,  Langenbeck, 
199. 

disarticulation  at  the,  267. 
Annandale's  operation  for  webbed  fingers, 

301. 
Antiseptic  fluid,  Thiersch's,  51. 

protective,  48. 

receptacle  for  instruments,  21. 

solutions,  22. 

spray  apparatus,  48. 
Antrum,  perforation  of  the,  484. 
Anus,  absence  of,  403. 

artificial,  373. 

examination  of,  401. 

imperforate,  402. 
Aorta,  abdominal,  ligature  of,  60. 
Aorta,  abdominal,  linear  guide  to,  60. 
Apparatus,  antiseptic  spray,  48. 

douching,  49. 

for  enterectomy,  Treves',  365. 
Arch,  palmar,  superficial,  ligature  of,  106. 
Arch,  palmar,  superficial,  linear  guide  to, 

106. 
Arm,  amputation  of  the,  248. 

by  large  anterior  and  small  posterior  flaps, 
250. 

by  musculocutaneous  flaps,  Langenbeck, 
249. 

circular-flap  method,  248. 

unequal  double-flap  method,  249. 
Arteries,  ligature  of,  56. 

general  considerations,  56. 

guides  to,  56. 

iliac,  62. 

instruments  required  for,  59. 

operations  on  special,  60. 
Artery,  abdominal  aorta,  ligature  of,  60. 


INDEX. 


517 


Artery,  abdominal  aorta,  linear  guide  to,  60. 

axillary,  first  portion,  ligature  of,  95. 

axillary,  first  portion,  liuear  guide  to,  95. 

axillary,  ligature  of,  95. 

axillary,  third  portion,  ligature  of,  97. 

axillary,  third  portion,  linear  guide  to,  97. 

brachial,  ligature  of,  98. 

brachial,  linear  guide  to,  99. 
Artery,  carotid,  common,  ligature  of,  106. 

common,  linear  guide  to,  107. 

common,  ligature  of  both,  110. 

external,  ligature  of,  110. 

external,  linear  guide  to,  110. 

internal,  ligature  of,  111. 
Artery,  dorsalis  pedis,  ligature  of,  82. 

dorsalis  pedis,  linear  guide  to,  82. 

dorsalis  penis,  ligature  of,  69. 

epigastric,  ligature  of,  71. 

epigastric,  linear  guide  to,  71. 

facial,  ligature  of,  1 1 5. 

femoral,  deep,  ligature  of,  77. 

femoral,  ligature  of,  7-. 

femoral,  linear  guide  to,  72. 

gluteal,  ligature  of,  66. 

gluteal,  linear  guide  to,  66. 
Artery,  iliac,  circumflex,  deep,  ligature  of,  71. 

iliac,  common,  ligature  of,  62. 

iliac,  external,  ligature  of,  69. 

iliac,  internal,  ligature  of,  65. 
Artery,  innominate,  ligature  of,  86. 

lingual,  ligature  of,  113. 

lingual,  linear  guide  to,  113. 

mammary,  internal,  ligature  of,  94. 

mammary,  internal,  linear  guide  to,  95. 

occipital,  ligature  of,  116. 

peroneal,  ligature  of,  85. 

peroneal,  linear  guide  to,  85. 

popliteal,  ligature  of,  77. 

popliteal,  linear  guide  to,  77. 

profunda  femoris,  ligature  of,  77. 

pudic,  internal,  ligature  of,  68. 

pudic,  internal,  linear  guide  to,  68. 

radial,  ligature  of,  101. 

radial,  linear  guide  to,  101. 

sciatic,  ligature  of,  67. 

sciatic,  linear  guide  to,  67. 

subclavian,  ligature  of  first  portion,  left 
side,  87. 

subclavian,  ligature  of  first  portion,  right 
side,  89. 

subclavian,  ligature  of  second  portion,  92. 

subclavian,  ligature  of  third  portion,  90. 

subclavian,  second  portion,  linear  guide 
to.  - 

subclavian,  third  portion,  linear  guide  to, 
8:*. 

oral,  ligature  of,  116. 

thyroid,  inferior,  ligature  of.  95. 

thyroid,  inferior,  linear  guide  t".  98 

thyroid,  superior,  ligature  «f,  118. 

tibial,  anterior,  ligature  <>f,  79. 

tibial,  anterior,  linear  guide  to,  79. 

tibial,  posterior,  ligature  <>f,  8:>. 

tibial,  posterior,  linear  guide  to,  h::. 

ulnar,  ligature  <<(',  104, 


Artery,  ulnar,  linear  guide  to,  104. 
vertebral,  ligature  of,  92. 
vertebral,  linear  guide  to,  93. 
Arthrectomy,  508. 
Artificial  anus,  373. 
Artificial  hemostatics,  24. 
Artificial  respiration,  14,  54. 
Aspiration  of  the  bladder,  421. 
Assistants  at  operations,  40. 
Astragaloid  osteotomy,  Stokes',  303. 
Astragalus,  excision  of,  199. 
Auricularis   magnus   nerve,  operations  on, 

146. 
Axillary  artery,    first    portion,    ligature  of, 

95. 
Axillary  artery,  first  portion,  linear  guide 

to,  95. 
Axillary  artery,  ligature  of,  95. 
Axillary  artery,  third  portion,  ligature  of, 

97. 
Axillary  artery,  third  portion,  linear  guide 

to,  97. 
Axillary  glands,  extirpation  of  the,  481. 

Bandages,  24. 

elastic,  24,  54. 
Battery,  electric,  53. 
Bauden's   amputation    at    tarso-metatarsal 

joint,  262. 
Bichloride-of-mercury  dressing,  51. 
Bilateral  lithotomy,  450. 

Nelaton's  modification  of,  451. 
Billroth's   operation    for   excision   of    the 

tongue,  342. 
Birth-mark,  132. 
Bladder,  aspiration  of  the,  421. 

digital  exploration  of  the,  422. 

extroversion  of  the,  423. 

extroversion  of  the,  F.  F.  Maury's  opera- 
tion, 423. 

extroversion  of  the,  Pancoast's  operation, 
424. 

extroversion   of  the,  Wood's   operation, 
424. 

stone  in  the,  427. 

operations  on  the,  410. 

puncturing  the,  425. 

puncturing  the,  through  the  rectum,  426. 

puncturing  the,  under  the  pubes,  426. 

rupture  of  the,  421. 
Bloodless  stretching  of  sciatic  nerve,  great, 

148. 
Bone-forceps,  136,  168. 
Bones,  operations  on,  162. 

excision,  165. 

gouging,  162. 

osteotomy,  212 

s<  i|iiestrotomy,  163. 

sequestrotomy,  direct  method,  164. 

sequestrotomy,  indirect  method,  165. 

wiling  of,  in  compound  fractures,  512. 
Bourgary's  excision  of  bonea  of  forearm, 

lower  extremities  of,  192. 
Bow  legs,  221. 
Brachial  artery,  ligature  of,  98. 


518 


INDEX. 


Brachial  artery,  linear  guide  to,  99. 

Brachial  plexus,  operations  on,146. 

Brandis'  tourniquet,  abdominal,  287. 

Breast,  extirpation  of  the,  480. 

Brisement  force,  29V. 

Bronchi,  foreign  bodies  in  the,  505. 

Bronchotomy,  492. 

Bruns'  amputation  at  ankle-joint,  272. 

Buchanan's  medio-lateral  operation  of  lithot- 
omy, 451. 

Buck's  operation  of  cheiloplasty,  for  lower 
lip,  322. 
interno  -  lateral    flap   method   of    cheilo- 
plasty of  upper  lip,  325. 
semicircular  flap  method  of  cheiloplasty 
of  uppper  lip,  325. 

Bull's  (W.  T.)  transfusion  of  saline   solu- 
tions. 130. 

Bunion,  302. 

Calcaneum,  excision  of,  198. 
Canalization,  Neuber,  4V. 
Cancer  of  the  rectum,  412. 
Capillaries,  operations  on,  131. 
division  and  ligaturing,  134. 
subcutaneous  ligaturing,  132. 
Carden's  amputation  at  the  knee-joint,  282. 
Carotid  artery,  common,  ligature  of,  106. 
common,  linear  guide  to,  107. 
external,  ligature  of,  110. 
external,  linear  guide  to,  110. 
internal,  ligature  of,  111. 
Carotid  arteries,  common,  ligature  of  both, 

110. 
Carpo-metacarpal    articulation,   amputation 
of  the  thumb  at,  by  lateral-flap  method, 
241. 
by  oval  method,  240. 
Castration,  458. 
Catgut  ligatures,  39. 
how  prepared,  40. 
Catheter,  introduction  of  a,  into  the  blad- 
der, 417. 
Catheterization,  417. 
Cautery,  actual,  35. 
galvano-,  37. 
thermo-,  36. 
Celsus'  circular  amputation  of  thigh,  285. 
method    of    cheiloplasty   for  lower   lip, 
321. 
Cheever's  operation  for  removal  of  naso- 
pharyngeal polypi,  489. 
Chiene's  osteo-arthrotomy,  220. 
Cheiloplasty,  320. 

Buck's  method  of,  for  lower  lip,  322. 
Buck's  interno-lateral  flap  method  of,  for 

upper  lip,  325. 
Buck's  semicircular  flap  method  of,  for 

upper  lip,  325. 
Celsus'  method  of,  for  lower  lip,  321. 
deformity  of  lower  lip,  V-shaped  incision, 

320. 
Dieffenbach's  operation  of,  for  upper  lip, 

326. 
horizontal  incision  for  lower  lip,  321. 


Cheiloplasty,  Malgaigne's  operation  of,  for 
lower  lip,  324. 

Sedillot's  operation  of,  for  lower  lip,  324. 

Sedillot's  vertical-flap  method  of,  for  up- 
per lip,  326. 

Syme's  operation  of,  for  lower  lip,  322. 
Chloroform,  6. 

inhaler,  Esn.arch's,  6. 

poisoning  bv,  or  overdose  of,  treatment 
for,  14. 
Cholecystectomy,  361. 
Cholecystotomy,  360. 
Chopart's  amputation  through  medio-tarsal 

joint,  262. 
Circumclusion,  32. 
Circumcision,  458. 
Cirsoid  growths,  134. 
Clavicle,  excision  of,  180. 
Clean  towels  and  old  linen,  22. 
Clover's  elher  inhaler,  9. 
Cocaine,  17. 
Cock's  operation  of  tapping   the   urethra, 

478. 
Colotomy,    left   inguinal,   linear    guide   to, 
372. 

left  inguinal,  Littre,  372. 

left  lumbar,  Amussat,  368. 

left  lumbar,  linear  guide  to,  368. 

right  lumbar,  372. 
Compresses,  26. 
Compress,  graduated,  26. 
Cone,  ether,  simplest  form  of,  7. 
Continuous  suture,  44,  349. 
Contraction  of  palmar  fascia,  160. 
Cotton-batting  dressing,  49. 
Cripp's  operation  of  excision  of  the  rectum, 

413. 
Crural  nerve,  anterior,  operations  on,  149. 
Curvature  of  the  spine,  298. 
Czerny's  operation  for  radical   cure  of  in- 
guinal hernia,  387. 
Czerny-Lambert  intestinal  suture,  351. 

Davy's  lever,  29,  288. 
Decalcified  drainage-tubes  of  Neuber,  47. 
Deep  circumflex  iliac  artery,  ligature  of,  71. 
Deformities,  297. 

of  upper  lip,  325. 
Deformity  of  lower  lip,  V-shaped  incision, 

320. 
De  Lignerolle's  amputation,  subastragaloid, 

264. 
Delpech's  operation  of  urethroplasty,  470. 
De  Morgan's  incision  for  spinal  accessory 

nerve,  146. 
Dental  nerve,  inferior,  operations  on,  144. 
Deviation  of  the  septum  nasi,  491. 
Dieffenbach's  amputation  at  the  hip-joint, 
292. 
operation  of  cheiloplasty  for  the  upper  lip, 

326. 
operation  of  rhinoplasty,  310. 
operation  of  urethroplasty,  470. 
Digital  pressure,  27. 
Disarticulation  at  the  ankle-joint,  267. 


INDEX. 


519 


Disarticulation,  at  the  elbow-joint,  247. 

at  the  hip-joint,  287. 

at  the  knee-joint,  278. 

at  medio-tarsal  joint,  264. 

at  the  metacarpophalangeal  articulation, 
239. 

at  the  metatarsophalangeal  joint,  258. 

at  the  phalangeal  articulations  of  the  foot, 
256. 

at  the  phalangeal  articulations  of  the  hand, 
237. 

at  the  shoulder-joint,  250. 

at  the  tarso-metataisal  joints,  260. 

at  the  wrist-joint,  244. 

of  the  Sngers,  237. 

of  the  last  four  metacarpal  bones,  243. 

of  the  toes,  256. 

sub-astragaloid,  264. 
Dorsalis-pe  lis  artery,  ligature  of,  69. 

linear  guide  to,  82. 
Dorsalis-penis  artery,  ligature  of,  82. 
Douching  apparatus,  49. 
Dowell's  operation  for  radical  cure  of  in- 
guinal hernia,  388. 
Dubrueil's  amputation  at  the  wrist-joint,  245. 
Duodenostomy,  356. 

Duplay's  operation  for  hypospadias,  465. 
Dupuytren's  amputation  at  shoulder-joint, 
250. 

contraction,  160. 

contraction,  operation  for,  160. 
Drainage  of  wounds,  46. 
Drainage,  spiral,  Ellis',  46. 
Drainage-tube,  decalcified,  of  Xeuber,  47. 

rubber,  46. 
Dressing,  open,  53. 
Dressings,  bichloride  of  mercury,  51. 

combined,  49. 

cotton  batting,  49. 

iodoform,  49. 

peat,  50. 

protective,  48. 

Elastic  bandages,  24,  54. 
Elbow-joint,  amputation  at,  247. 

amputation  at,  circular  method,  247. 

amputation  at,  single-flap  method,  248. 

disarticulation  at  the,  247. 

excision  of,  Hiiter,  189. 
Electric  battery.  5:;. 
Ellis'  drainage  spiral,  46. 
Elongated  uvula,  :;:;.") 
Emergencies,  special,  54. 
Empty  ressels,  21. 
Engine,  surgical,  169. 
Enterectomy,  864. 

Treves'  apparatus  for,  365. 
Enterotomy,  868. 

right  inguinal,  Xelaton's  operation  of,  363. 
Epigastric  artery,  ligature  of,  71. 

linear  guide  to,  71. 
Epispadias,  467. 

Nelaton'e  operation  for,  467. 

Thiersch'!  operation  lor,  ins. 
Erector  spina-,  tenotomy  of,  159. 


Esmarch's  chloroform  inhaler,  6. 
Esmarch's  modification  of  Lc  Fort's  ampu- 
tation at  ankle-joint,  273. 
Esmarch's  operation  for  anchylosis  of  infe- 
rior maxilla,  179. 
Esmarch's  tourniquet,  abdominal,  2S7. 
Ether,  5. 

amount  required  to  produce  anaesthesia,  10. 

cone  or  inhaler,  simplest  form,  7. 

dangers  from  use  of,  11. 

method  of  administering,  13. 

treatment  for  poisoning  by,  or  overdose 
of,  14. 
Ether  inhaler,  Allis',  8. 

Clover's,  9. 

Lente's  modified,  9. 

Xoyes',  10. 

simplest  form  of  cone,  7. 

Squibbs',  10. 
Etherization,  intestinal,  15. 
Excision  of  the  ankle-joint,  199. 

of  ankle-joint,  subperiosteal,  Langenbeck, 
199. 
Excision  of  the  astragalus,  199. 
Excision   of   bones   of   forearm,  lower  ex- 
tremities of,  Bourgary,  192. 
Excision  of  the  bones  of  the  leg,  202. 
Excision  of  the  calcaueum,  198. 
Excision  of  clavicle,  180. 
Excision  of  elbow-joint,  Hiiter,  189. 

of  the  elbow-joint,  Liston,  190. 

of  elbow-joint,  subperiosteal,  Langenbeck, 
190. 
Excision  of  the  fibula,  202. 
Excision  of  great  trochanter  of  femur,  207. 
Excision  of  hip-joint,  208. 

subperiosteal,  Langenbeck,  209. 

Savre,  211. 

White,  208. 
Excision  of  humerus,  185. 

head  of,  subperiosteal,  Langenbeck,  186. 

lower  extremity  of,  1S8. 

shaft  of,  187. 

upper  end  of,  Langenbeck,  185. 
Excision  of  the  knee-joint,  202. 

by  transverse  incision,  207. 

non-subperiosteal,  Mackenzie.  204. 

subperiosteal,  Langenbeck,  205. 

subperiosteal,  Oilier,  206. 
Excision  of  joints  of  lower  extremities,  197. 
Excision  of  maxilla?,  both,  174. 
Excision  of  maxilla,  inferior,  175. 

alveolar  process,  178. 

central  portion,  176. 

half  of,  177. 

lateral  portion  of  bodv,  1 76. 

whole  of,  178. 
Excision  of  maxilla,  superior,  170. 

below  floor  of  orbit,  17-i. 

by  median  incision,  with  removal  of  the 
whole  bone,  1 72. 

subperiosteal,  173. 
Excision   of    metacarpo-phalangeal    joints, 

197. 
Excision  of  nerves,  141. 


520 


INDEX, 


Excision  of  the  patella,  207. 

Excision  of  phalangeal  joints  of  hand,  197. 

Excision  of  the  radius,  192. 

Excision  of  the  rectum,  412. 

Cripp's  operation,  413. 

Maisonneuve's  operation,  414. 

Volkmann's  operations,  413. 
Excision  of  rib,  portion  of,  180. 
Excision  of  scapula,  182. 

body  of,  183. 

for  malignant  growths,  184. 

glenoid  angle  of,  187. 

subperiosteal,  Oilier,  184. 
Excision  of  scrotum,  122. 
Excision  of  the  sternum,  179. 
Excision  of  the  tibia,  202. 
Excision  of  the  tongue,  339. 

Billroth's  operation,  342. 

Heart's  operation,  342. 

Knox's  operation,  342. 

Kocher's  operation,  343. 

Regnoli's  operation,  342. 

Sedillot's  operation,  342. 
Excision  of  the  tonsils,  337. 
Excision  of  the  ulna,  192. 
Excision  of  wrist -joint,  193. 

of  the  wrist-joint,  complete,  Langenbsck, 
194. 
Exploration,  digital,  of  the  bladder,  422. 
Extensor  communis  digitorum,  tenotomy  of, 
153. 

longus  digitorum,  tenotomy  of,  156. 

ossis  metacarpi  pollicis,  tenotomy  of,  153. 

primi  internodii  pollicis,  tenotomy  of,  153. 

proprius  pollicis,  tenotomy  of,  156. 

secundi  internodii  pollicis,  tenotomy  of, 
153. 

quadriceps  cruris,  tenotomy  of,  157. 
Extirpation  of  the  axillary  glands,  480. 

of  the  breast,  480. 

of  the  parotid  gland,  481. 

of  the  penis,  Gouley,  463. 
Extroversion  of  the  bladder,  F.  F.  Maury's 
operation,  423. 

Pancoast's  operation,  424. 

Wood's  operation,  424. 
Extremities,  lower,  excision  of  joints  of,  197. 

Facial  artery,  ligature  of,  115. 
Facial  nerve,  operations  on,  145. 
Fasciotomy,  151. 
Fascia,  palmar,  159. 

Dupuytren's  contraction  of,  160. 

Dupuytren's  operation  for  contraction  of, 
160. 
Fascia,  plantar,  159. 
Fecal  fistula,  373. 
Femoral  artery,  ligature  of,  72. 

linear  guide  to,  72. 

deep,  ligature  of,  77. 
Femur,  great  trochanter  of,  excision  of,  207. 

neck  of,  subcutaneous  division  of,  Adams, 
216. 
Fergusson's  amputation  at  the  ankle-joint, 
271. 


Ferguson's  operation  of  uranoplasty,  334. 
Fibula,  excision  of  the,  202. 
Fingers,  disarticulation  of  the,  237. 
Fingers,  webbed,  300. 

Annandale's  operation,  301. 

Nekton's  operation,  301. 
Fistula  in  ano,  404. 

incision  with  closure,  407. 

operation  by  direct  incision,  406. 

treatment  by  ligaturing,  407. 
Fistula,  fecal,  373. 
Fistula,  salivary,  335. 

Horner's  operation,  336. 

operation  by  a  seton,  336. 
Flat  foot,  Ogsten's  operation,  302. 
Fletcher's  aneurism  needle,  60. 
Flexor,  biceps  cruris,  tenotomy  of,  157. 

biceps  cubiti,  tenotomy  of,  154. 

carpi  radialis,  tenotomy  of,  153. 

carpi  ulnaris,  tenotomy  of,  154. 

longus  digitorum,  tenotomy  of,  154. 

longus  pollicis,  tenotomy  of,  155. 

profundus  digitorum,  tenotomy  of,  153. 

sublimis  digitorum,  tenotomy  of,  153. 
Fluid,  antiseptic,  Thiersch's,  51. 
Foot,  flat,  Ogsten's  operation,  302. 
Forceps,  artery,  33. 

bone,  136,  163. 

bone-holding,  167,  235. 

needle,  42,  332. 

throat,  348. 

thumb,  18. 

wire-twisting,  329. 
Fore-arm,  amputation  of,  246. 

circular  method,  246. 

equilateral  skin-flaps,  246. 

musculo- cutaneous  flaps,  247. 
Foreign  bodies  in  the  bronchi,  505. 
Forbes'    amputation    through    the    medie- 

tarsal  joint,  264. 
Fractures,  compound,  wiring  of  bones  in, 

512. 
French  operation  of  rhinoplasty,  307. 

Gall-bladder,  operations  on  the,  360. 
Galvano-cautery,  37. 
Ganglion,  511. 
Gastro-enterostomy,  355. 
Gastrostomy,  353. 
Gauze,  iodoform,  50. 
Gely's  intestinal  suture,  350. 
General   considerations   of    operative    sur- 
gery, 1. 

nursing,  3. 

place  for  operation,  3. 

season  of  year,  2. 

temperature  of  room,  3. 

time  of  day,  3. 
Genu  valgum,  218. 

osteotomy  for,  218. 
Genu  varum,  osteotomy  for,  220. 
Giraldcs'  operation  for  hare-lip,  318. 
Gland,  parotid,  extirpation  of  the,  482. 
Glands,  axillary,  extirpation  of  the,  480. 
Glover's  suture,  44. 


INDEX. 


521 


Gluteal  artery,  ligature  of,  66. 

Goitre,  removal  of  a,  Watson,  508. 
Gouley's  operation  for  extirpation  of   the 

penis,  463. 
Gouley's  operation  for  hypospadias,  464. 
Gracilis,  tenotomy  of,  157. 
Graduated  compress,  26. 
Grafting,  skin,  30*7. 

Gritti's  amputation  at  the  knee-joint,  2S3. 
Grooved  director,  18. 
Guide,  linear,  to  abdominal  aorta,  60. 

to  axillary  artery,  first  portion,  95. 

to  axillary  artery,  third  portion,  97. 

to  brachial  artery,  99. 

to  carotid  artery,  common,  107. 

to  carotid  artery,  external,  110. 

to  dorsalis  pedis  artery,  82. 

to  epigastric  artery,  71. 

to  femoral  artery,  72. 

to  gluteal  artery,  66. 

to  iliac  arteries,  common,  62. 

to  iliac  artery,  external,  69. 

to  left  inguinal  colotomy,  372. 

to  left  lumbar  colotomy,  368. 

to  lingual  artery,  113. 

to  mammary  artery,  internal,  95. 

to  palmar  arch,  superficial,  106. 

to  peroneal  artery,  85. 

to  popliteal  artery,  77. 

to  pudic,  internal,  artery,  63. 

to  radial  artery,  101. 

to  sciatic  artery,  67. 

to  subclavian  artery,  second  portion,  89. 

to  subclavian  artery,  third  portion,  89. 

to  thyroid  artery,  inferior,  95. 

to  tibial  artery,  anterior,  79. 

to  tibial  artery,  posterior,  83. 

to  ulnar  artery,  104. 

to  vertebral  artery,  93. 
Guides,  whalebone,  introduction  of,  420. 
Gussenbauer's  intestinal  suture,  351. 

Hallux  valgus,  222. 

Hancock's     subastragaloid    disarticulation, 

266. 
Hare-lip,  315. 

complicated,  319. 

double  (simple),  319. 

simple,  317. 

simple  double-flap  operation,  318. 

Giraldes'  operation,  318. 

simple  single -flap  operation,  317. 

suture-,   15. 
Heart's  operation  for  excision  of  the  tongue, 

842. 
Hcaton's  operation  for  radical  cure  of  in- 
guinal hernia,  381. 
Hemorrhage,  agents  for  controlling,  23. 
Hemorrhoids,  1 19. 

Hemorrhoids,  internal,  operations  for,  119. 
bing,  120. 

excision,  1 19. 

injection,  121, 

ligaturing,  120. 

ligaturing  with  incision,  120. 


Hemostatics,  artificial,  24. 
Hernia,  380. 

femoral,  radical  cure  for,  Wood's  opera- 
tion, 388. 

femoral,  strangulated,  397. 
Hernia,  inguinal,  radical  cure  for,  Agnew's 
operation,  383. 

Czerny's  operation,  387. 

Dowell's  operation,  388. 

Ilcaton's  operation,  381. 

Wood's  operation,  384. 

Wood's  operation  with  pins,  386. 

Wiitzer's  operation,  3S2. 
Hernia,  inguinal,  strangulated,  395. 
Hernia,  obturator,  strangulated,  401. 
Hernia,  strangulated,  390. 
Hernia,  umbilical,  389. 
Hernia,  umbilical,  strangulated,  400. 
Hey's  amputation  at  tarso-metatarsal  joint, 

262. 
Hilton's  amputation  of  the  penis,  462. 
Hip-joint,  amputation  at,  287. 

anterior  oval  method,  Verneuil,  296. 

circular  method,  Dieffenbach,  292. 

lateral-flap  method,  296. 

long   anterior   and   short   posterior  flap, 
Maenec,  290. 

single-flap  method,  Malgaigne,  293. 
nip-joint,  excision  of,  208. 

Say  re,  211. 

subperiosteal,  Langenbeck,  209. 

White,  20S. 
Hip-joint,  disarticulation  at  the,  287. 
Holder,  needle,  42. 

Horner's  operation  for  salivary  fistula,  336. 
Horse-hair  sutures,  43. 
Humerus,  excision  of,  185. 

of  lower  extremity  of,  188. 

of  shaft  of,  187. 

subperiosteal  of  head  of,  Langenbeck,  185. 

of  upper  end  of,  Langenbeck,  186. 
Humphrey's  amputation  of  the  penis,  463. 
Hiiter's  excision  of  elbow-joint,  189. 
Hydrocele,  455. 

incision  of  sac  of,  456. 

incision  with  excision  of  part  of  sac,  456. 

injection  of  sac,  457. 

injection  of  sac,  accidents  after,  457. 

tapping  of  sac  of,  455. 
Hydrocephalus,  134. 
Hydro-rachis,  135. 
Hypertrophy  of  the  tongue,  340. 
Hypospadias,  463. 

Anger's  operation,  464. 

Duplay's  operation,  465. 

Gouley's  operation,  464. 

Szymanowski's  operation,  466. 

Iliac  artery,  circumflex,  deep,  ligature  of,  71. 
Iliac  arteries,  common,  ligature  of,  62. 

linear  guide  to,  62. 
Iliac  artery,  external,  ligature  of,  69. 

linear  guide  to,  69. 
Iliac  artery,  internal,  ligature  of,  65. 

linear  guide  to,  66. 


522 


INDEX. 


Imperforate  anus,  402. 

Imperforate  rectum,  414. 

Incisions,  20. 

Indian  method  of  rhinoplasty,  311. 

Infra-orbital  nerve,  operations  on,  142. 

Ingrowing  toe-nail,  302. 

Inhaler,  chloroform,  Esmarch's,  6. 

Inhaler,  ether,  Allis',  8. 

Clover's,  9. 

Lente's  modified,  9. 

Noyes',  10. 

simplest  form  of  cone,  7. 

Squibb's,  10. 
Inhalers  for  anaesthetics,  7. 
Innominate  artery,  ligature  of,  86. 
Inorganic  or  metallic  sutures,  43. 
Instrumental  pressure  for  controlling  hemor- 
rhage, 28. 
Instruments  necessary  for  the  performance 

of  an  operation,  18. 
Instruments,  receptacle  for,  21. 
Instruments  should  be  plain,  21. 
Internal  cesophagotomy  for  stricture,  346. 
Interrupted  suture,  44. 
Intestinal  etherization,  15. 
Intestinal  sutui'e,  Czerny-Lambert,  351. 

Gely's,  350. 

Gussenbauer's,  351. 

Jobert's,  350. 

Lembert's,  350. 
Intubation  of  the  larynx,  O'Dwyer,  503. 
Iodoform  dressing,  49. 
Iodoform  gauze,  50. 
Italian  method  of  rhinoplasty,  312. 

Jaw,  lower,  anchylosis  of,  178. 

Esmarch's  operation  for,  179. 
Jaw,  lower,  excision  of,  175. 

of  alveolar  process  of,  178. 

of  central  portion  of,  176. 

of  half  of,  177. 

of  lateral  portion  of  body  of,  176. 

of  whole  of,  178. 
Jaws,  upper,  excision  of  both,  174. 
Jaw,  upper,  excision  of,  170. 

below  floor  of  orbit,  173. 

by  median  incision,  with  removal  of  whole 
bone,  172. 

subperiosteal,  173. 
Jejunostomy,  356. 
Jobert's  intestinal  suture,  350. 
Joint,  ankle,  amputation  at,  Esmarch's  modi- 
fication of  Le  Fort's,  273. 

Pirogoff,  270. 

Pirogoff's,  Bruns'  modification  of,  272. 

Pirogoff 's,  Fergusson's  modification  of ,  271 . 

Pirogoff's,  Le  Fort's  modification  of,  272. 
Joint,  ankle,  amputation  at,  removal  of  en- 
tire foot,  Syme,  267. 

removal  of   entire  foot,  modification  of 
Syme's,  268. 

removal  of  entire  foot,  Roux's  modifica- 
tion of  Syme's,  269. 
Joint,  ankle,  disarticulation  at  the,  267. 
Joint,  ankle,  excision  of,  199. 


Joint,  ankle,  subperiosteal,  Langenbeck,  199. 
Joint,  carpo-metacarpal,  amputation  at,  240. 
Joint,  elbow,  amputation  at,  247. 

circular,  247. 

single  flap,  248. 
Joint,  elbow,  disarticulation  at  the,  247. 
Joint,  elbow,  excision  of,  Hiiter,  189. 

Liston,  190. 

subperiosteal,  Langenbeck,  190. 
Joint,  hip,  amputation  at,  287. 

anterior  oval  method,  Verneuil,  296. 

circular  method,  Dieffenbach,  292. 

lateral-flap  method,  296. 

long   anterior   and   short   posterior  flap, 
Maenec,  290. 

single-flap  method,  Malgaigne,  293. 
Joint,  hip,  disarticulation  at  the,  287. 
Joint  hip,  excision  of,  208., 

Sayre,  211. 

subperiosteal,  Langenbeck,  209. 

White,  208. 
Joint,  knee,  amputation  at,  278. 

bilateral  method,  279. 

circular  method,  280. 

long  anterior,  with  a  short  posterior  flap, 
281. 

through  the  condyles,  Garden,  282. 

through  the  condyles,  Gritti,  2S3. 

through  the  condyles,   Stokes'  modifica- 
tion of  Gritti's,  283. 
Joint,  knee,  disarticulation  at  the,  278. 
Joint,  knee,  excision  of,  202. 

by  transverse  incision,  207. 

non-subperiosteal,  Mackenzie,  204. 

subperiosteal,  Langenbeck,  205. 

subperiosteal,  Oilier,  206. 
Joint,  knee,  osteotomy  lor  bony  anchylosis 

of,  217. 
Joint,    medio-tarsal,    amputation  through, 
Chopart,  262. 

Forbes'  modification  of  Chopart's,  264. 
Joint,  metacarpophalangeal,  amputation  at, 
239. 

disarticulation  at,  239. 

excision  of,  197. 
Joint,  metatarso-phalangeal,  amputation  of 
all  the  toes  at,  258. 

disarticulation  at  the,  258. 
Joint,  shoulder,  amputation  above  the,  255. 
Joint,  shoulder,  amputation  at  the,  250. 

by  circular  incision,  252. 

by  internal  and  external  flaps,  Dupuvtrcn, 
250. 

oval  method,  Larrey,  252. 

Spence's  method,  253. 
Joint,  shoulder,  disarticulation  at  the,  250. 
Joint,   subastragaloid,   amputation    at,   De 
Lignerolle's,  264. 

subastragaloid,  Hancock's,  266. 

subastragaloid,  Tripier's,  266. 
Joint,    tarso-metatarsal,    amputation,    Lis- 
franc,  260. 

Bauden's  modification  of,  262. 

Hey's  modification  of,  262. 

Skey's  modification  of,  262. 


INDEX. 


523 


Joint,  wrist,  amputation  at,  244. 

circular  method,  244 

double-flap  method,  Ruyscb,  244. 

radial  flap,  Dubrueil,  245. 

single  palmar  flap,  246. 
Joint,  wrist,  disarticulation  at  the,  244. 
Joint,  wrist,  excision  of,  193. 

complete,  Langenbeck,  194. 
Joints,  movable  bodies  in,  510. 
Joints  of   lower   extremities,    excision    of, 

197. 
Joints,  phalangeal,  of  foot,  amputation  at, 
256. 

disarticulation  of  the,  256. 

excision  of  the,  197. 
Joints,  phalangeal,  of  hand,  amputation  at, 
287. 

disarticulation  of  the,  237. 

excision  of  the,  197. 
Joints,  tarso-metatarsal,  disarticulation  at 
the,  260. 

Kelotomy,  392. 

Keves'  operation  for  varicocele,  124. 

Knee-joint,  amputation  at,  278. 

bilateral  method,  279. 

circular  method,  280. 

lonjj  anterior,  with  a  short  posterior  flap, 
281. 

through  the  condyles,  Carden,  282. 

through  the  condyles,  Gritti,  283. 

Stokes'  modification  of  Gritti's,  283. 
Knee-joint,  disarticulation  at  the,  278. 
Knee-joint,  excision  of,  202. 

by  transverse  incision,  207. 

non-subperiosteal,  Mackenzie.  204. 

subperiosteal,  Langenbeck,  205. 

subperiosteal,  Oilier,  206. 
Knee-joint,  osteotomy  for  bonv  anchylosis 

of,  217. 
Knife,  amputating,  manner  of  grasping  the, 

230. 
Knife,  amputating,  the  catlin,  231. 
Knives,  amputating,  230. 
Knot,  reef  or  square,  38. 
Knots,  38. 
Knox's  operation  for  excision  of  the  tongue, 

S42. 
Kocher's    operation    for    excision   of    the 
tongue,  343. 

Langenbeck's     amputation    of    the     arm, 

~24  9. 
Langenbeck's  excision  of  the  ankle-joint, 
•periosteal,  199. 
of  the  elbow-joint,  subperiosteal,  190. 
of  the  hip-joint,  subperiosteal,  -1"-'. 
ol  tli"  humerus,  head  of,  subperiosteal, 

1  .so. 
<>f  humerus,  upper  end  of,  186. 
of  knee-joint,  subperiosteal.  205. 
of wrist  joint,  complete,  19 1. 
Langenbeck's  method  of  amputation,  228. 
Langentx  sk'e  operation  for  removal  of  nasal 
polypi,  187. 


Langenbeck's  operation  for  removal  of  naso- 
pharyngeal polypi,  488. 

of  rhinoplasty,  808. 
Lannelongue's     operation    cf    uranoplasty, 

334. 
Laparotomy  or  abdominal  section,  362. 

explorative,  362. 
Larrev's  amputation  at  the  shoulder-joint, 

2*52. 
Laryngectomy,  506. 
Laryngotomy,  497. 

sub-hyoid,  506. 
Laryngo-tracheotomy,  501. 

rapid,  .St.  Germain,  501. 
Larynx,  intubation  of  the,  O'Dwyer,  503. 
Larynx,  surgical  anatomy  of  the,  493. 
Lateral  lithotomy,  441. 
Latissimus  dorsi,  tenotomy  of,  158. 
Le  Fort's  amputation  at  the  ankle-joint,  272. 
Left  lumbar  colotomy,  Amussat,  368. 
Leg,  amputation  of  the,  at  the  lower  third, 
274. 

at  the  lower  third,  bilateral  method,  276. 

at  the  lower  third,  circular,  with  periosteal 
reflection,  274. 

at  the  lower  third,  hood  or  oval  flap,  277. 

supra-malleolar,  274. 

through  the  middle  third,  277. 

through  middle  third,  unilateral-flap  meth- 
od, 278. 

at  the  upper  third,  279. 
Leg,  excision  of  the  bones  of  the,  202. 
Lembert's  suture,  intestinal,  350. 
Lente's  ether  inhaler,  modified,  9. 
Lever,  Davy's,  29,  228. 
Ligature  of  abdominal  aorta,  60. 
Ligature  of  arteries,  56. 

general  considerations  of,  56. 

guides  to,  56. 

instruments  required  to,  59. 
Ligature  of  axillary  artery,  95. 

first  portion,  95. 

third  portion,  97. 
Ligature  of  brachial  artery,  98. 
Ligature  of  carotid  arteries,  common,  both, 

110. 
Ligature  of  carotid  artery,  common,  106. 

external,  110. 

internal,  111. 
Ligature  of  dorsalis  pedis  artery,  82. 

of  dorsalis  penis  artery,  69. 

of  epigastric  artery,  71. 

of  facial  artery,  115. 

of  femoral  artery,  72. 

of  femoral  artery,  deep,  77. 

of  gluteal  artery,  66. 
Ligature  ol'  iliac  artery,  common,  G2. 

circumflex,  deep,  71. 

external,  (ill. 

internal,  65. 
Ligature  of  innominate  artery,  86. 

of  lingual  artery,  113. 

of  mammary  artery,  internal,  94. 

of  occipital  artery,  i  i  <i. 

of  palmar  arch,  .superficial,  106. 


524 


INDEX. 


Ligature  of  peroneal  artery,  85. 

of  popliteal  artery,  77. 

of  pudic  artery,  internal,  68. 

of  radial  artery,  101. 

of  sciatic  artery,  67. 
Ligature  of  subclavian  artery,  first  portion, 
left  side,  87. 

of  first  portion,  right  side,  89. 

of  second  portion,  92. 

of  third  portion,  90. 
Ligature  of  temporal  artery,  116. 

of  thyroid  artery,  inferior,  95. 

superior,  113. 
Ligature  of  tibial  artery,  anterior,  79. 

posterior,  82. 
Ligature  of  ulnar  artery,  104. 

of  veins,  117. 

of  vertebral  artery,  92. 
Ligatures,  37. 

catgut,  how  prepared  antiseptically,  40. 

hemp  and  silk,  how  prepared  antisepti- 
cally, 39. 
Linear  guide  to  abdominal  aorta,  60. 

to  axillary  artery,  first  portion,  95. 

to  axillary  artery,  third  portion,  97. 

to  brachial  artery,  99. 

to  carotid  artery,  common,  107. 

to  carotid  artery,  external,  110. 

to  dorsaiis  pedis  artery,  82. 

to  epigastric  artery,  71. 

to  femoral  artery,  72. 

to  gluteal  artery,  66. 

to  iliac  arteries,  common,  62. 

to  iliac  artery,  external,  69. 

to  left  inguinal  colotomy,  372. 

to  left  lumbar  colotomy,  368. 

to  lingual  artery,  113. 

to  mammary  artery,  internal,  95. 

to  palmar  arch,  superficial,  106. 

to  peroneal  artery,  85. 

to  popliteal  artery,  77. 

to  pudic  artery,  internal,  68. 

to  radial  artery,  101. 

to  sciatic  artery,  67. 

to  subclavian  artery,  second  portion,  89. 

to  subclavian  artery,  third  portion,  89. 

to  thyroid  artery,  inferior,  95. 

to  tibial  artery,  anterior,  79. 

to  tibial  artery,  posterior,  83. 

to  ulnar  artery,  104. 

to  the  vertebral  artery,  93. 
Lingual  artery,  ligature  of,  113. 

linear  guide  to,  113. 
Lingual  nerve,  operations  on,  145. 
Lip,  lower,  Buck's  operation  of  cheiloplasty 
for,  322. 

Celsus'  method  of  cheiloplasty  for,  321. 

Malgaigne's  operation  of  cheiloplasty  for, 
324. 

Sedillot's   operation  of   cheiloplasty  for, 
324. 

Syme's    operation    of    cheiloplasty    for, 
322. 
Lip,     upper,    Buck's     interno-lateral    flap 
method  of  cheiloplasty,  325. 


Lip,  Buck's  semicircular-flap  method  of  chei- 
loplasty, 325. 
deformities  of  the,  325. 
Dieffenbach's  operation   of    cheiloplasty 

for,  326. 
entire  loss  of  the,  325. 
Sedillot's  vertical  flap  method  of  cheilo- 
plasty, 326. 
Lisfranc's  amputation  at  the  tarso-metatar- 

sal  joint,  260. 
Lister's  excision  of  the  wrist- joint,  195. 
Lister's  tourniquet,  abdominal,  2S7. 
Litholapaxy,  432. 
Lithotomy,  440. 

bilateral  operation,  450. 
bilateral   operation,   Nekton's    modifica- 
tion of,  451. 
lateral,  441. 
median,  447. 
medio-bilateral,  452. 
medio-lateral  operation,  Buchanan,  451. 
supra-pubic,  452. 
Lithotomy  in  the  female,  454. 
vesico-vaginal,  455. 
urethral,  455. 
Lithotrite,  introduction  of  the,  429. 
Lithotrity,  428. 

combined  crushing  and  evacuating,  436. 
in  the  female,  440. 
perineal,  437. 
rapid,  432. 
Littre's  operation  for  left  inguinal  coloto- 
my, 372. 
Lloyd's  tourniquet,  abdominal,  289. 
Loreta's  operation  for  divulsion  of  the  pylo- 
rus, 359. 
Loreta's   retrograde  divulsion  for  stricture 

of  the  oesophagus,  346. 
Lumbar  plexus,  branches  of,  149. 

Macewen's   supra-condyloid    osteotomy    for 

genu  valgum,  218. 
Mackenzie's   non-subperiosteal  excision    of 

knee-joint,  204. 
Maenec's  amputation  at  hip-joint,  290. 
Maisonneuve's  operation  of  excision  of  the 

rectum,  414. 
Malgaigne's  amputation  at  hip-joint,  293. 
Malgaigne's   operation  of   cheiloplasty  for 

lower  lip,  324. 
Mammary  artery,  internal,  ligature  of,  94. 

linear  guide  to,  95. 
Maxillae,  superior,  excision  of  both,  174. 
Maxilla,  inferior,  anchylosis  of,  178. 

Esmarch's  operation  for,  179. 
Maxilla,  inferior,  excision  of,  175. 

alveolar  process  of,  178. 

central  portion  of,  176. 

half  of,  177. 

lateral  portion  of  body  of,  176. 

whole  of,  17$. 
Maxilla,  superior,  excision  of,  170. 

below  floor  of  orbit,  173. 

by  median  incision,  with  removal  of  whole 
"  bone,  172. 


INDEX. 


525 


Maxilla,  superior,  excision  of,  subperiosteal, 
173. 

Maxillary   nerve,    superior,   operations    on, 
142. 

Maury's  (F.  F.)  operation  for  extroversion 
of  the  bladder,  423. 

Mechanical  apparatus  for  loss  of  nasal  sep- 
tum, 310. 

Mechanical  means  employed  in  uranoplasty, 
334. 

Median  lithotomy,  447. 

Median  nerve,  operations  on,  147. 

Medio-bilateral  lithotomy,  452. 

Medio-lateral  lithotomy,  Buchanan,  451. 

Medio-tarsal  joint,  amputation  at,  Chopart, 
262. 
Forbes'  modification  of  Chopart's,  264. 

Meningocele,  135. 

Metacarpal  bones,  amputation  of  last  four, 
243. 
amputation  through  the,  242. 
disarticulation  of  the  last  four,  243. 

Metacarpophalangeal  articulation,  amputa- 
tions at,  239. 
disarticulation  at,  239. 
joints,  excision  of,  197. 

Metatarsal    bones,   amputation   through  all 
the,  258. 

Metatarsophalangeal    joint,    disarticulation 
at  the,  258. 

Metallic  sutures,  43. 

Mikulicz's   osteoplastic   amputation  at   the 
ankle-joint,  273. 

Moliere's  amputation  at  ankle,  266. 

Mother's  mark,  132. 

Mott's  aneurism  needle,  59. 

Movable  bodies  in  joints,  510. 

Multifidus  spina?,  tenotomy  of,  158. 

Musculo-cutaneous    nerve,    operations    on, 
147. 

Musculo-spiral  nerve,  operations  on,  117. 

Naevus,  132. 

operations  for,  132. 
Nail,  toe,  ingrowing,  302. 
Nares,  posterior,  plugging  the,  4S4. 
Nasal  polypi,  removal  of,  485. 

Langenbeck's  operation,  487. 

Nelaton's  operation,  488. 
Nasal  septum,  mechanical  apparatus  for  loss 

of,  310. 
Naso  pharyngeal  polypi,  removal  of,  Checv- 
operation,  480. 

Langenbeck's  operation,  488. 
Needle,  aneurism,  59. 

Fletcher's,  60. 

Mott's,  -v.'. 

"stud  rots',"  60. 

Byrne' 
Needle  forceps  or  holders,  42. 
Nelaton's  modification  of  the  bilateral  op- 

eration  of  lithotomy,  151. 
Nelaton'i   operation   of   e.-iterotomy,   right 
inguinal,  808, 

for  epispadias,  467. 


Nelaton's  operation  for  removal  of  nasal 
polypi,  488. 

of  urethroplasty,  470. 

for  webbed  fingers,  301. 
Nephrectomy,  374. 

abdominal,  375. 

lumbar,  375. 
Nephrolithotomy,  376. 
Nephrorraphy,  376. 

Nerve,    auricularis   magnus,  operations  on, 
146. 

crural,  anterior,  operations  on,  149. 

dental,  inferior,  operations  on,  144. 

facial,  operations  on,  146. 

infra-orbital,  operations  on,  142. 

lingual,  operations  on,  145. 

maxillary,  superior,  operations  on,  142. 

median,  operations  on,  146. 

musculo-cutaneous,  operations  on,  147. 

musculo-spiral,  operations  on,  146. 

occipital,  great,  operations  on,  145. 

perineal,  operations  on,  149. 

plantar,  operations  on,  149. 

popliteal,  external,  operations  on,  148. 

popliteal,  internal,  operations  on,  148. 

radial,  operations  on,  147. 

saphenous,  external  or  short,  operations 
on,  150. 

saphenous,  internal   or   long,  operations 
on,  150. 

sciatic,  great,  operations  on,  147. 

sciatic,  small,  operations  on,  148. 

spinal  accessory,  operations  on,  146. 

supra-orbital,  operations  on,  141. 

tibial,  anterior,  operations  on,  148. 

tibial,  posterior,  operations  on,  148. 

ulnar,  operations  on,  117. 
Nerves,    branches   of    brachial   plexus   of, 

operations  on,  146. 
Nerves,  excision  of,  141. 
Nerves  of  the  cranium,  operations  on,  141. 
Nerves,  spinal,  operations  on,  145. 
Nerves,  stretching  of,  141. 
Nerves,  suturing  of,  150. 
Nerves,  transplantation  of,  151. 
Neuber's  canalization,  47. 
Neuber's  decalcified  drainage-tubes,  47. 
Nitrous  oxide,  7. 
Non-subperiosteal    excision   of    knee-joint, 

Mackenzie,  204. 
Noyes'  ether  inhaler,  10. 

Occipital  artery,  ligature  of,  116. 
Occipital  nerve,  great,  operations  on,  145. 
O'Dwycr's  intubation  of  the  larynx,  503. 
(Esophagectomy,  346. 
(Esophagostomy,  :; :  7. 
(Esophagotomy,  344. 

internal,  for  stricture,  846. 
Oesophagus,  removal  of  foreign  bodies  from, 
347. 

stricture  of  the,  315. 

stricture  of  the,  retrograde  divulsion  for, 
Loreta,  346. 
Ogsten's  osteo-arthrotomy,  220. 


526 


INDEX. 


Ogsten's  operation  for  flat-foot,  302. 
Ollier's   operation   for   osteoplastic    rhino- 
plasty, 313. 
Ollier's  subperiosteal  excision  of  knee-joint, 

206. 
Ollier's  subperiosteal  excision  of   scapula, 

184. 
Open  dressing  for  wounds,  53. 
Operating  table,  21. 

Operation,  antiseptic,  preparation  for,  52. 
Operations,  assistants  at,  40. 

nursing  after,  3. 

place  for,  3. 

preparatory  treatment  for,  4. 

requirements,  essential,  4. 

requirements,  necessary,  4. 

requirements,  precautionary,  53. 

season  of  year  for,  2. 

surroundings  of  patient  after,  3. 

temperature  of  room  after,  3. 

time  of  day  for,  3. 
Operations  on  bones,  162. 

excision,  165. 

gouging,  162. 

osteotomy,  212. 

sequestrotomy,  163. 

sequestrotomy,  direct  method,  164. 

sequestrotomy,  indirect  method,  165. 
Operations  on  the  gall-bladder,  360. 
Operations  on  hollow  viscera  in  contact  with 

serous  surfaces,  348. 
Operations  on  special  arteries,  60. 
Operations  on  the  palate,  329. 
Operations  on  the  stomach,  352. 
Operation  wounds,  treatment  of,  41. 
Operative  surgery,  general  considerations,  1. 
Osteo-arthrotomy,  Chiene,  220. 

Ogsten,  220. 

Reeves,  220. 
Osteoplastic  amputation  of  heel  and  ankle, 

Mikulicz,  273. 
Osteoplastic  rhinoplasty,  313. 

Ollier's  method,  313. 

Pancoast's  method,  314. 

Sabine,  T.  T.,  314. 
Osteotomy,  212. 

for  genu  varum,  220. 

inter-trochanteric,  Sayre,  217. 

inter-trochanteric,  Volkmann,  217. 

supra-condyloid,  for   bony  anchylosis  of 
knee-joint,  217. 

supra-condyloid,  for   genu  valgum,  Mac- 
ewen,  218. 

astragaloid,  Stokes,  303. 

Palate,  operations  upon  the,  329. 
Palmar  arch,  superficial,  ligature  of,  106. 

linear  guide  to,  106. 
Palmar  fascia,  159. 

Dupuytren's  contraction  of,  160. 

Dupuytren's  operation  for  contraction  of, 
160. 
Pancoast's  operation  for  extroversion  of  the 
bladder,  424. 

operation  for  rhinoplastic  osteoplasty,  314. 


Pancoast's  tourniquet,  abdominal,  287. 
Paracentesis  abdominis,  377. 
Paracentesis  thoracis,  483. 
Paraphymosis,  461. 
Parotid  gland,  extirpation  of  the,  482. 
Patella,  excision  of,  207. 

wiring  the,  509. 
Peat  dressing,  50. 
Pectineus,  tenotomy  of,  158. 
Penis,  amputation  of  the,  old  plan,  462. 

Hilton's  modification,  462. 

Humphrey's  modification,  463. 
Penis,  extirpation  of  the,  Gouley's  opera- 
tion, 463. 
Perforation  of  the  antrum,  484. 
Pericardium,  tapping  the,  479. 
Perineal  lithotrity,  437. 
Perineal  nerve,  operations  on,  149. 
Perineal  section,  471. 
Perineal  urethrotomy,  external,  471. 

with  a  guide,  472. 

without  a  guide,  473. 
Perityphlitic  abscess,  373. 
Peroneal  artery,  ligature  of,  85. 

linear  guide  to,  85. 
Peroneus  brevis,  tenotomy  of,  155. 
Peroneus  longus,  tenotomy  of,  155. 
Peroneus  tertius,  tenotomy  of,  156. 
Phalangeal  articulations  of  the  hand,  am- 
putations at  the,  237. 

of  the  hand,  disarticulation  at,  237. 

of  the  foot,  disarticulation  at,  256. 
Phalangeal  joints,  excision  of,  197. 
Pharyngotomy,  506. 
Phlebotomy,  125. 
Pins,  acupressure,  32. 
Pirogoff's    amputation   at   the   ankle-joint, 

270. 
Plantar  fascia,  operations  on,  159. 
Plantar  nerve,  operations  on,  149. 
Plaster-of-Paris  jacket,  Sayre's,  for  curva- 
ture of  the  spine,  298. 
Plastic  surgery,  304. 

preparation  of  patient,  304. 

size  of  flap,  304. 
Plastic  surgery,  methods  of  transfer,  305. 

grafting,  307. 

inversion  or  evcrsion,  306. 

jumping,  306. 

skin-grafting,  307. 

sliding,  305. 

Taliacotian  operation,  306. 
Plexus  of  nerves,    brachial,  operations  on 
branches  of,  146. 

lumbar,     operations     on     branches     of, 
149. 
Plugging  the  posterior  nares,  484. 
Polypi,  nasal,  removal  of,  4S5. 

Langenbeck's  operation,  487. 

Nelaton's  operation,  488. 
Polypi,  naso-pharyngeal,  removal  of,  Chcev- 
er's  operation,  489. 

Langenbeck's  operation,  488. 
Popliteal  artery,  ligature  of,  77. 

linear  guide  to,  77. 


INDEX. 


527 


Popliteal  nerve,  external,  operations  on,  148. 

internal,  operations  on,  148. 
Precautionary  requirements  for  operations, 

53. 
Preparations  for  an  antiseptic  operation,  52. 

assistants,  52. 

douching,  52. 

instruments,  52. 

operating-table,  52. 

operator,  52. 

patient,  52. 

the  wound,  52. 
Pressure,    digital,   for    controlling    hemor- 
rhage, 27. 

instrumental,  for  controlling  hemorrhage, 
28. 
Proctotomy,  external,  412. 
Prolapsus  ani,  409. 
Protective,  antiseptic,  48. 

dressings,  48. 
Pudic  artery,  internal,  linear  guide  to,  68. 

ligature  of,  08. 
Puncturing  the  bladder,  425. 

through  the  rectum,  426. 

under  the  pubes,  426. 
Pylorus,   divulsion   of,  Loreto's   operation, 

359. 
Pylorus,  resection  of  the,  356. 

Quadriceps   extensor   cruris,    tenotomy    of, 

157. 
Quilled  suture,  45. 

Radial  artery,  ligature  of,  101. 

linear  guide  to,  101. 
Radial  nerve,  operations  on,  147. 
Radius,  excision  of,  192. 
Ranula,  338. 
Rapid    larvngo  traeheotomv,    St.    Germain, 

501. 
Rapid  lithotrity,  432. 

Receptacle,  antiseptic,  for  instruments,  21. 
Rectal  examination,   introduction  of  whole 

hand,  409. 
Rectotomy,  412. 
[tectum,  cancer  of  the,  412. 
Rectum,  excision  of  the,  412. 

<  Iripp's  operation,  413. 

Maisonneuve'a  operation,  414. 

Volkmarm's  operations,  413. 
Rectum,  imperforate,  414. 

stricture  of  the,  414. 
peal  anatomy  of,  408. 
Reef  or  square  knot,  38. 
I:  ■  Jteo-arthrotomy,  220. 

Regnoli'e  excision  of  tin-  tongue,  342. 
Removal  of  a  goitre,  Watson,  508. 
Removal  of  nasal  polypi,  486. 

Langenbeck's  operation,  187. 

Nelaton'e  operation,  488. 
I  il  of  aaso-pharyngeal  polypi,  Cheer 

operation,  i  9. 

Langenbeck's  operation,  488. 
Requirements,    precautionary,    for    opera. 
tion 


Resection  of  the  pylorus,  356. 
Respiration,  artificial,  14,  54. 
Retractors,  59. 
Retroclusion,  32. 
Rhinoplasty,  307. 

Dieffenbach's  operation,  310. 

French  operation,  307. 

Indian  operation,  311. 

Italian  operation,  312. 

Langenbeck's  operation,  308. 

loss  of  the  bony  or  cartilaginous  septum, 
with  or  without  loss  of  nasal  bones, 
309. 
Rhinoplasty,  osteoplastic,  313. 

Ollier's  operation,  313. 

Pancoast's  operation,  314. 

Sabine,  T.  T.,  314. 
Rib,  excision  of  a  portion  of  a,  180. 
Ricord's  operation  for  varicocele,  125. 
Rigaud's  operation  of  urethroplasty,  470. 
Rod,  Trendelenburg's,  31,  288. 
Roux's  amputation  at  ankle-joint,  269. 
Rubber  drainage-tube,  46. 
Rupture  of  the  bladder,  421. 
Ruysch's  amputation  at  the  wrist-joint,  244. 

Sabine,  T.  T.,  osteoplastic  rhinoplasty,  314. 
Saline  solutions  for  transfusion,  129,  130. 
Salivary  fistula,  335. 
Horner's  operation,  336. 
operation  by  a  seton,  336. 
Saphenous  nerve,  external  or  short,  opera- 
tions on,  150. 
internal  or  long,  operations  on,  150. 
Sartorius,  tenotomy  of,  157,  158. 
Sayre's  excision  of  hip-joint,  211. 
intertrochanteric  osteotomy,  217. 
plaster-of-Paris  jacket   for  curvature  of 
the  spine,  298. 
Saw,  amputating,  proper  method  of  using 

an,  233. 
Saws,  amputating,  232. 
Scalpel,  method  of  holding,  18. 
Scapula,  excision  of,  182. 
body  of,  183. 

for  malignant  growths,  184. 
glenoid  angle  of,  187. 
subperiosteal,  Oilier,  184. 
Schwartz's  saline  solution  for  transfusion, 

130. 
Sciatic  artery,  ligature  of,  67. 

linear  guide  to,  67. 
Sciatic  nerve,  great,  operations  on,  146. 

small,  operations  on,  147. 
Scissors,  20. 

Scrotum,  excision  of,  122. 
Section,  abdominal,  862. 

explorative,  862. 
Sedillot'a  amputation  of  thigh,  286. 

operation  for  removal  of  the  tongue,  342. 
operation  of  chciloplasty,  for  lower  lip, 

824. 
vertical-flap   method   of  cheiloplasty  of 
upper  lip,  826. 
Semi-membranosus,  tenotomy  of,  157. 


528 


INDEX. 


Semi-tendinosus,  tenotomy  of,  157. 
Septum  nasi,  deviation  of  the,  491. 
Sequestrotomy,  163. 

direct  method,  164. 

indirect  method,  165. 
Serrefines,  83. 
Shock,  55. 

treatment  of,  55. 
Shoulder-joint,  amputation  above,  255. 
Shoulder-joint,  amputation  at,  250. 

by  circular  incision,  252. 

by  internal  and  external  flaps,  Dupuytren, 
250. 

oval  method,  Larrey,  252. 

Spence's  method,  253. 
Shoulder-joint  disarticulation  at  the,  250. 
Silk  ligatures,  how  prepared  antiseptically, 

39. 
Skey's  amputation  at  tarso-metatarsal  joint, 

262. 
Skin-grafting,  307. 
Solutions,  antiseptic,  22. 

saline,  for  transfusion,  129,  130. 
Sound,  introduction  of  a,  into  the  bladder, 

417. 
Special  emergencies,  54. 
Spence's  amputation  at  the  shoulder-joint, 

253. 
Spinal     accessory     nerve,    operations    on, 

14S. 
Spine,  curvature  of,  298. 

Sayre's  plaster-of-Paris  jacket  for,  298. 
Spiral  drainage,  Ellis',  46. 
Splenectomy,  377. 
Spray  apparatus,  antiseptic,  48. 
Square  or  reef  knot,  38. 
Squibb's  ether  inhaler,  10. 
Staphyloplasty,  335. 
Staphylorrhaphy,  operation  of,  830. 
Sterno-cleido-mastoid,  tenotomy  of,  159. 
Sternum,  excision  of,  179. 
St.   Germain's  operation  of  rapid  laryngo- 

tracheotomy,  501. 
Stimulants,  53. 
Stokes'  amputation  at  knee-joint,  283. 

astragaloid  osteotomy,  303. 
Stomach,  operations  on  the,  352. 
Stomatoplasty,  327. 
Stone  in  the  bladder,  427. 
Strangulated  hernia,  390. 

femoral,  397. 

inguinal,  395. 

obturator,  401. 

umbilical,  400. 
Stretching  of  nerves,  141. 

bloodless,  of  the  sciatic  nerve,  148. 
Stricture  of  the  oesophagus,  345. 

of  the  urethra,  operations  for,  471. 

of  the  rectum,  414. 
"  Students'  "  aneurism  needle,  60. 
Styptics,  24. 

Subastragaloid   disarticulation,    De    Ligne- 
rolles,  264. 

Hancock,  266. 

Tripier,  266. 


Subclavian  artery,  ligature  of  first  portion, 
left  side,  87. 

of  first  portion,  right  side,  89. 

of  second  portion,  92. 

of  third  portion,  90. 
Subclavian   artery,    second   portion,   linear 
guide  to,  89. 

third  portion,  linear  guide  to,  89. 
Sub-hyoid  laryngotomy,  506. 
Subperiosteal  excision  of  ankle-joint,  Lan- 
genbeck,  199. 

of  elbow-joint,  Langenbeck,  190. 

of  hip-joint,  Langenbeck,  209. 

of  hip -joint,  Say  re,  211. 

of  humerus,  head  of,  Langenbeck,  186. 

of  jaw,  upper,  173. 

of  knee-joint,  Langenbeck,  205. 

of  knee-joint,  Oilier,  206. 

of  maxilla,  superior,  1*73. 

of  scapula,  Oilier,  184. 
Supra-malleolar    amputation    of    the    leg, 

274. 
Supra-orbital  nerve,  operations  on,  141. 
Supra-pubic  lithotomy,  452. 
Surgical  engine,  169. 
Suture,  continuous,  44,  349. 

different  forms  of,  44. 

glover's,  44. . 

hare-lip,  45. 

horse-hair,  43. 

inorganic,  43. 

interrupted,  44. 

intestinal,  Czerny-Lembert,  351. 

Gely's,  350. 

Gussenbauer's,  351. 

Jobert's,  350. 

Lembert's,  350. 

metallic,  43. 

quilled,  45. 

twisted,  45. 
Sutures,  42. 
Suturing  of  nerves,  150. 

of  tendons,  161. 
Syme's  amputation  at  ankle-joint,  267. 
Syme's  aneurism  needle,  60. 
Syme's  operation  of  cheiloplasty  for  lower 

lip,  322. 
Szumann's  saline  solution  for  transfusion, 

130. 
Szymanowski's  operation  for  hypospadias, 

466. 
Szymanowski's  operation  of  urethroplasty, 
471. 

Table,  operating,  21. 
Tapping  hydrocele,  455. 

the  pericardium,  479. 

the  urethra,  Cock,  478. 
Tarsal  amputations,  irregular,  Moliere,  266. 
Tarsectomy,  303. 

Tarso-metatarsal  joint,  amputation  at,  Lis- 
franc,  260. 

Bauden's  modification  of,  262. 

Hey's  modification  of,  262. 

Skey's  modification  of,  262. 


INDEX. 


529 


Tarso-mctatarsal    joints,    disarticulation  at 

the,  260. 
Taxis,  391. 

Teale's  method  of  amputation,  22S. 
Temporal  artery,  ligature  of,  116. 
Tenaeula,  33,  34,  53. 
Tendo  Achillis,  tenotomy  of,  155. 
Tendon  suturing,  161. 
Tenotomy,  151. 

in  lower  extremities,  154. 

in  upper  extremities,  1 53. 

of  adductor  longus,  15S. 

of  biceps  flexor  cruris,  157. 

of  biceps  flexor  cubiti,  154. 

of  erector  spina?,  159. 

of  extensor  communis  digitorum,  1 53. 

of  extensor  longus  digitorum,  156. 

of  extensor  ossis  metacarpi  pollicis,  153. 

of  extensor  primi  internodii  pollicis,  153. 

of  extensor  proprius  pollicis,  156. 

of   extensor   secundi   internodii    pollicis, 
153. 

of  flexor  carpi  radialis,  153. 

of  flexor  carpi  ulnaris,  154. 

of  flexor  longus  digitorum,  154. 

of  flexor  longus  pollicis,  155. 

of  flexor  profundus  digitorum,  153. 

of  flexor  sublimis  digitorum,  153. 

of  gracilis,  157. 

of  latissimus  dorsi.  158. 

of  multifidus  spina?,  158. 

of  pectineus,  158. 

of  peroneus  brevis,  155. 

of  peroneus  longas,  155. 

of  peroneus  tertius,  156. 

of  quadriceps  extensor  cruris,  158. 

of  sartorius,  157,  158. 

of  semi-mem branosus,  157. 

of  scmi-tendinosus,  157. 

of  sterno-cleido -mastoid,  159. 

of  tendo  Achillis,  155. 

of  tensor  vagina?  femoris,  158. 

of  tibialis  anticus,  155. 

of  tibialis  posticus,  151. 

of  trapezius,  159. 
Teasor  vaaina?  femoris,  tenotomy  of,  158. 
Tliermo-cautery,  36. 
Thiersch's  fluid,  antiseptic,  51. 

operation  for  epispadias,  4ii8. 
Thigh,  amputation  of,  283 

an:ero-posterior     musculo- integumentary 
flaps,  285. 

bilateral  method,  284. 

circular  integumentary  flap,  285. 

long  anterior  flap  method,  Sedillot,  286. 

single   circular    incision  method,  Celsus, 
285. 
Thumb,   amputation   of,  at  the  carpo-meta- 
carpal  articulation,  lateral-flap  method, 
211. 

oval  method,  2(0. 
Thumb  forceps,  18. 
Thyroid  artery,  inferior,  ligature  of,  95. 

linear  guide  to,  It."). 
Thyroid  artery,  superior,  ligature  of,  113. 
81 


Thvrotomy,  505. 

Tibia,  excision  of,  202. 

Tibial  artery,  anterior,  ligature  of,  79. 

linear  guide  to,  79. 
Tibial  artery,  posterior,  ligature  of,  82. 

linear  guide  to,  83. 
Tibialis  anticus,  tenotomy  of,  155. 
Tibialis  posticus,  tenotomy  of,  154. 
Tibial  nerve,  anterior,  operations  on,  148. 

posterior,  operations  on,  148. 
Toe,  amputation  of  the  fifth,  with  its  meta- 
tarsal bones,  259. 
lateral-flap  method,  259. 
of  great,  by  large  square  internal  flap, 

257. 
of  great,  with  its  metatarsal  bone,  259. 
Toe-nail,  ingrowing,  302. 
Toes,  amputation  of  all,  at  the  metatarso- 
phalangeal joint,  258. 
in  their  continuity,  255. 
of  single,  256. 
of  single,  lateral  flap,  256. 
of  two  adjoining,  257. 
Toes,  disarticulation  of  the,  256. 
Tongue,  excision  of  the,  339. 

below   or    through    the    jaw,    Regnoli's 

operation,  342. 
Billroth's  operation,  342. 
entire,  341. 

Heart's  operation,  342. 
Knox's  operation,  342. 
Kocher's  operation,  343. 
Regnoli's  operation,  342. 
Sedillot's  operation,  342. 
Tongue,  hypertrophy  of  the,  340. 
Tongue-tic,  338. 
Torsion,  32. 
Torsoclusion,  32. 

Tourniquet,  abdominal,  Biandis',  287. 
Esmarch's,  287. 
Lister's,  287. 
Lloyd's,  2S9. 
Pancoast's,  2S7. 
Towels,  clean,  22. 
Trachea,  surgical  anatomy  of,  493. 
Tracheotomy,  499. 

above  the  isthmus,  500. 
below  the  isthmus,  500. 
instruments,  495. 
through  the  isthmus,  501. 
Transfusion,  54,  126. 
arterial,  131. 

direct  from  arm  to  arm,  127. 
injection  of  milk,  131. 
injection  of  saline  solution,  Bull,  W.  T., 

'130. 
injection    of    saline    solution,    Schwartz, 

'130. 
injection    of    saline    solution,    Szumann, 
130. 
I  Trapezius,  tenotomv  of,  159. 
-  Trendelenburg's  rod,  31,  228. 
I  Trephining  the  cranium,  136. 

Treves'  apparatus  for  enterectomy,  365. 
;  Tripicr's  subastiagaloid  disarticulation,  266. 


530 


INDEX. 


Tube,  drainage,  rubber,  46. 

tracheotomy,  53. 
Twisted  suture,  45. 

Ulna,  excision  of,  192. 
Ulnar  artery,  ligature  of,  104. 

linear  guide  to,  104. 
Ulnar  nerve,  operations  on,  147. 
Uranoplasty,  Ferguson's  operation  of,  334. 

Lannelongue's  operation  of,  334. 

mechanical  means  employed  in,  334. 
Urethra,  tapping  the,  Cock,  4*78. 
Urethroplasty,  Delpech's  operation  of,  470. 
.    Dieffenbach's  operation  of,  470. 

Nelaton's  operation  of,  470. 

Rigaud's  operation  of,  470. 

Szymanovvski's  operation  of,  471. 
Urethrotomy,  internal,  475. 
Urethrotomy,  external  perineal,  471. 

with  a  guide,  472. 

without  a  guide,  473. 
Uvula,  elongated,  335. 

Varicocele,  121. 

compression,  123. 

compression  by  double  loop  of  Ricord,  125. 

compression  by  wires,  123. 

Keyes'  operation  for,  124. 

radical  treatment  for,  123. 

subcutaneous  ligaturing,  124. 

Videl's  operation  for,  123. 
Varicose  veins,  118. 
Veins,  air  in  the,  55. 

symptoms,  55. 

treatment  of,  55. 

treatment  of,  preventive,  55. 
Veins,  ligature  of,  117. 
Veins,  varicose,  operations  for,  118. 

acupressure,  118. 

injection,  118. 

subcutaneous  ligaturing,  118. 


Venesection,  125. 

Vertebral  artery,  ligature  of,  92. 

linear  guide  to,  93. 
Verneuil's  amputation  at  hip-joint,  296. 

operation  of  rhinoplasty,  311. 
Vesico-vaginal    lithotomy    in    the    female, 

455.   . 
Vessels,  empty,  21. 
Videl's  operation  for  varicocele,  123. 
Volkmann's     intertrochanteric    osteotomv, 

217. 
Volkmann's  operations  of  excision  of  the 

rectum,  413. 

Watson's  operation  for  removal  of  a  goitre, 

508. 
Webbed  fingers,  300. 

Annandale's  operation,  301. 

Nekton's  operation,  301. 
Whalebone  guides,  introduction  of,  420. 
White's  excision  of  hip-joint,  208. 
Wiring  of   bones   in   compound  fractures, 
512. 

the  patella,  509. 
Wood's  operation  for  extroversion  of  the 
bladder,  424. 

for  radical  cure  of  femoral  hernia,  388. 

for  radical  cure  of  inguinal  hernia,  384. 

for  radical  cure  of  inguinal  hernia  with 
pins,  386. 
Wounds,  operation,  treatment  of,  41. 
Wrist-joint,  amputation  at,  244. 

circular  method,  244. 

double-flap  method,  Ruysch,  244. 

radial  flap,  Dubrueil,  245. 

single  palmar  flap,  245. 
Wrist-joint,  disarticulation  at  the,  244. 

excision  of,  193. 

excision  of,  complete,  Langenbeck,  194. 
Wiitzer's  operation  for  radical  cure  of  in- 
guinal hernia,  382. 


THE   END. 


TEXT-BOOK  OF  OPHTHALIOSGOPY. 

By  EDWARD   G.  LORING,  M.  D. 

PART  I. 

The  Normal  Eye,  Determination  of  Refraction,  Diseases  of 

the  Media,  Physiological  Optics,  and  Theory  of 

the  Ophthalmoscope. 

8vo,  267  pages,  with  131  Illustrations,  and  Four  Chromo-Lithograph  Plates, 

CONTAINING   FOURTEEN    FIGURES.       PRICE,    CLOTH,    $5.00. 


CONTENTS: 

I.  Remarks  on  the  Ophtlialmoseope. — Examination  by  Dayliglit. — Examina- 
tion of  the  Eye  by  Artificial  Ligbt.  II.  Examination  with  the  Ophthalmoscope. 
— Method  of  Examination. — Examination  ty  the  Inverted  Image. — Examination 
by  the  Upright  Image.  III.  The  Anatomy  of  the  Fundus  of  the  Normal  Eye. 
IV.  The  Fundus  of  the  Norma!  Eye  as  seen  with  the  Ophthalmoscope. — Anom- 
alies. V.  Determination  of  the  Optical  Condition  of  the  Eye  with  the  Ophthal- 
moscope.— Refraction. —Astigmatism. — Refraction,  according  to  the  Standard 
of  the  Inch. — Directions  in  case  the  Observer  is  Ametropic. — Determination  of 
the  Refraction  of  the  Eye  by  the  Mirror  alone,  and  by  means  of  the  Inverted 
Image. — Astigmatism  with  the  Mirror  alone. — Astigmatism  with  the  Inverted 
Image. — Amount  of  Enlargement  produced  by  Upright  Image.  VI.  Examina- 
tion of  the  Media  of  the  Eye. — Oblique  Illumination. — The  Aqueous  Humor. — 
The  Iris. — The  Lens. — Opacities  of  the  Lens. — Examination  of  the  Media  by  the 
Ophthalmoscope.— The  Iris. — The  Lens. — Vitreous  Humor,  and  Fundus  of  the 
Eye. — Differential  Diagnosis  of  Troubles  in  the  Media. — Entozoa. 

Appendix. — General  Principles  of  the  Ophthalmoscope. — Physiological  Op- 
tics.— Theory  of  the  Ophthalmoscope. — The  Metric  System. — Ophthalmoscopes. 
— Adjuncts  to  the  Ophthalmoscope. 

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Biggs,  M.D.     Illustrated.     8vo.     Cloth,  $2.50. 

HUXLEY  (T.  H.).  The  Anatomy  of  Vertebrated  Animals.  Illustrated.  12mo. 
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HUXLEY  (THOMAS  HENRY).  The  Anatomy  of  Invertebrated  Animals 
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JOHNSON  (JAMES  F.  W.).  The  Chemistry  of  Common  Life.  A  new  edition, 
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Illustrated  with  Maps  and  numerous  Engravings  on  Wood.  12mo.  Cloth, 
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LUYS  (J.).  The  Brain  and  its  Functions.  With  Illustrations.  12mo.  Cloth, 
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6 

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